A north-east health board has apologised to a patient after a report found there had been significant failings in its diagnosis of lung cancer.
The Scottish Public Services Ombudsman (SPSO) asked NHS Grampian to apologise to patient C and inform them of what actions would be taken in the future to ensure the same situation would not happen again.
C had been in contact with specialists at NHS Grampian as they suspected they had lung cancer.
The SPSO ruled that there had been a significant delay in the diagnosis of lung cancer which resulted from an “unreasonable failure of radiological interpretation” which led to a significant injustice to C and resulted in shortening their life.
It added that there was also an unreasonable failure to follow up test results or carry out a further scan, however acknowledged this would not have changed the outcome for the patient.
C also said there was a tumour visible in tests carried out by specialists, however this was missed by the health board which was unreasonable, however the SPSO took independent advice from three specialists and found that C’s treatment was in fact reasonable.
The decision report said: “C had been in contact with a number of specialists at the health board as C suspected they were symptomatic of lung cancer.
“C said that a tumour in their lung was visible from a number of tests carried out by hospital specialists, but that this was unreasonably missed.
“C also said that treatment decisions and management were not reasonable and that the failure to diagnose them with lung cancer within a reasonable time had catastrophic consequences for their prognosis. C was also concerned about the way the health board dealt with their complaint.
“We took independent advice from three advisers. We found that C’s treatment was reasonable. C was regularly reviewed and their antibiotics were changed in order to try and improve their outcome.
“However, we found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which lead to significant injustice to C; this failure would shorten C’s life. We also found an unreasonable failure to follow up test results or to carry out a further scan.
“In relation to the standard of respiratory care and treatment provided, we found that the diagnostic process and treatment decisions were reasonable.
“Finally, we found significant failings in the health board’s investigation of C’s complaint. While the health board identified radiological errors, they did not apologise for these or explain how they occurred and what action the health board were taking to ensure they did not happen again, nor was there any consideration of the impact of these errors on C’s prognosis and treatment decisions.”
The SPSO said that NHS Grampian should change a number of things to help put things right in the future.
This included carrying out an audit of x-rays and scans in a specific time-period to ensure there is not systemic issue which may have affected other patients, follow up test results appropriately, feedback the findings of the investigation to staff, review the complaints handling failures and review the failures of radiological interpretation to find out how and why it occurred.
A spokesman for NHS Grampian said: “We accept the findings of the SPSO and its recommendations.
“This case unfortunately represents an occasion where we did not meet the high standards we aspire to.
“We have already apologised to C but would take this opportunity to do so again publicly.”