Mrs X complained about the length of time that her father (Mr Y) had to wait to be seen following a referral made by his GP in September 2012 for an endoscopy at the Royal Gwent Hospital. Mrs X highlighted that there had been a downgrading of the referral from urgent suspected cancer (USC) without her father having been seen and without any discussion with his GP. She was also concerned about the lack of clear ownership and responsibility for her father’s care. Mrs X said that there was a lack of cohesion between the differing specialities involved which resulted in communication failures. Mrs X was of the view that her father’s treatment and quality of life might have been improved if he had been seen in a more timely manner.
Mrs X also complained that the Health Board’s subsequent investigation into her complaint failed to accept responsibility and acknowledge the harm that was caused by the delay in Mr Y receiving attention.
In investigating the complaint the Ombudsman took account of the view of one of her Clinical Advisers. The Ombudsman found there to be unacceptable delays in the care provided and said that no sense of urgency was shown to Mr Y’s clinical condition. She said that there were shortcomings in the leadership and ownership of the care and treatment being provided to Mr Y.
The Ombudsman raised concern about inadequate communication with the GP and with Mr Y and his family.
The Ombudsman highlighted that the relevant Health Board policy did not comply with the NICE guidelines. The Ombudsman was also concerned about the waiting time for an urgent outpatient appointment.
She said there had been an unnecessary delay in an endoscopy procedure being carried out. The primary site of cancer was identified following this.
The Ombudsman upheld the concerns raised by Mrs X about the clinical care. She noted that although a more timely response would not have changed the sad outcome, it might have avoided the unnecessary psychological suffering felt by Mr Y and his family. It was also possible that a tracheostomy procedure could have been avoided.
The Ombudsman also upheld Mrs X’s complaint about the Health Board’s subsequent complaint investigation.
The Ombudsman recommended that the Health Board:
a. provide an apology to Mrs X for the significant shortcomings in her father’s care and treatment.
b. provide financial redress to Mrs X of £1500 for the distress caused to Mr Y and his family and £500 for the time and trouble incurred in making a complaint and for the shortcomings in the complaint response.
c. review the endoscopy referral criteria for USC to ensure consistency with the relevant NICE guideline.
d. ensure that the First Consultant Gastroenterologist considered the issues raised in this case.
e. take action to ensure that the unacceptable delays for urgent outpatient appointments are addressed.
f. review the process to ensure that abnormal results are acted upon urgently by a lead clinician or relevant cancer MDT.
g. review how it communicates effectively and appropriately with patients and their families, particularly when more than one speciality is involved.
h. comply with the “Putting Things Right” framework including a proper consideration of “qualifying liability” and seeking independent clinical advice in appropriate circumstances.
A full copy of the report is available below.