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Mrs C complained, through her solicitor, that the Health Board had failed to diagnose her brain tumour in a timely way; instead for over a year she was managed and treated for a stroke, and was later referred for a mental health assessment. Consequently, Mrs C said, she was not provided with earlier relief from the distressing symptoms she suffered and she was made to feel that her symptoms were psychosomatic. In addition, Mrs C complained about how the Health Board had dealt with her subsequent complaint.

The investigation found failings in Mrs C’s clinical management. The Ombudsman’s Independent Clinical Advisers said that Mrs C’s multiple admissions to hospital should have triggered consideration of an alternative diagnosis to a stroke much sooner. She ought to have been referred for an MRI scan and/or to a Neurologist. Two failed referrals could not be explained. The Consultant treating Mrs C for a stroke worked alone at the time; this was criticised as it gave no opportunity to discuss complex presentations. The referral requests to Radiology were found to be insufficient or illegible resulting in failed communication and misinterpretation of some images. This resulted in a 12 month period of additional distress for Mrs C albeit that, unfortunately, no surgical intervention could have been offered to her. There was some delay in the Health Board responding to requests made by Mrs C’s solicitor as part of her complaint. Mrs C’s complaints were upheld.

The Health Board agreed to all the Ombudsman’s recommendations:

• To apologise and offer redress of £2,500 to Mrs C for her distress as a result of the failings and delays identified.

• Through a Clinical Lead, to issue reminders to all staff of the need to provide accurate, clear requests to Radiology colleagues and also to properly evidence inter-clinician referrals clearly in the clinical records.

• Mrs C’s case should be used as a learning exercise and discussed at a joint meeting of all departments involved.

• The Radiology service should consider participating at an early stage in future Welsh trials of the electronic ordering of Radiology requests.

A full copy of the report is available below.