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Mrs P complained about her late husband Mr P’s treatment in what were his final weeks and about the handling of her complaint. Specifically, she complained about a delay in Mr P being seen on admission to hospital due to a bed shortage, a failure in diagnosing his brain cancer from a scan performed, and failures in his care and treatment (including being given a drug of limited prognostic benefit). Mrs P also complained about how Mr P was afterwards discharged home to her care without appropriate plans and services in place. She further complained about his discharge with medication (about which no advice or guidance had been offered) and also about a letter written to her by the Consultant treating Mr P after his death, which had caused her further distress.

Following an examination of clinical records, and advice from the Ombudsman’s clinical advisers, the following aspects of the complaint were not upheld: Whilst Mr P’s brain cancer had not been diagnosed from the scan this was within acceptable clinical practice on the part of an average radiologist, given the type of cancer was rare. However, given Mr P’s ongoing symptoms, consideration should have been given to a second opinion from a Neuroradiologist. Whilst recognising Mrs P’s distress in receiving the letter, at an emotional time, the Consultant had written it with the best of intentions. It was not, to the objective eye, insensitive or meant to cause her distress.

The following complaints were upheld: There had been a delay in Mr P’s admission. The course of clinical treatment offered to Mr P at that stage of his illness was not reasonable (given its slow response rate) in comparison with a treatment he could have been offered which may have prolonged his life expectancy even for a short time. Mr P was discharged home without proper arrangements in place. The discharge lacked effective communication with both Mr and Mrs P, and raised serious concerns surrounding controlled medication. The complaint handling concern was also upheld. The following recommendations were made, all of which the Health Board agreed to implement in full:

(a) A written apology to Mrs P and an offer of redress of £3,000 for her distress, time and trouble in pursuing her grievances and complaint handling delays.

(b) The preparation of an action plan dealing with the nursing care failings identified by the Ombudsman’s clinical adviser (relating to clinical care, patient discharge and record keeping).

(c) The case should be discussed at both Radiology and Cancer services meetings as a learning point, taking into account the critical comments of the Ombudsman’s clinical advisers. An action plan to deal with resulting actions to avoid recurrence should be prepared and shared with the Ombudsman.

A full copy of the report is available below.