Health chiefs have been told to make a series of changes after failing to spot a woman’s cancer had spread.
It follows a complaint made to the Scottish Public Service Ombudsman (SPSO) about the way the woman, who has since died, was treated by NHS Grampian.
According to the SPSO, the woman – who has not been named – was diagnosed with lung cancer and began to suffer from severe neck pain, which spread to her shoulder and arm.
The woman was admitted to Dr Gray’s Hospital at the request of her GP.
Clinical staff in the hospital’s acute medical assessment unit did not request an X-ray “given that a recent scan of the shoulder had shown no problems,” said an SPSO report.
The next day, the woman was discharged from hospital and allowed home. However, her pain continued and she was admitted to Aberdeen Royal Infirmary a few days later.
Staff there took X-rays and carried out a scan that showed the cancer had spread to two of the woman’s neck bones and her brain.
After her death, the woman’s husband sought help from an advocacy and support agency, which complained to the SPSO about her treatment.
The agency claimed NHS Grampian had failed to provide the woman with adequate care and treatment during her admission to Dr Gray’s Hospital.
In its report, the SPSO said: “We took independent advice from a consultant in acute medicine.
“The adviser’s view was that the possibility of the cancer spreading to the (neck) or the spinal cord should have been considered, that there should have been a discussion with the oncology and that the use of steroids and an MRI scan should have been considered.
“The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.”
NHS Grampian told the SPSO it acknowledged it should have referred the woman to the oncology team and that a neck X-ray ought to have been performed.
“They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of the woman’s pain,” the SPSO report said.
“NHS Grampian explained they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team,” the report added.
“They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their (internal computer system) and documentation in induction packs. We have asked the board to provide evidence of these actions.”
An NHS Grampian spokeswoman said: “We fully accept the findings in this case and would take this opportunity to apologise again. “All recommendations made by the SPSO have been implemented.”