Reviews ordered on diagnosis delays
Wednesday 25th September 2013, 5:20PM BST.
A man who coughed up blood for a year before being diagnosed with cancer and a woman who complained of back pain for a week and was then told she had a fractured spine have prompted reviews by the public service watchdog.
Scottish Public Service Ombudsman Jim Martin has ordered a serious clinical incident review at Edinburgh Royal Infirmary after staff missed a man’s cancer for a year when a simple examination would have revealed the problem.
He also raised serious concerns about a consultant at Stirling Royal Infirmary who missed a serious spinal fracture, leaving a woman in pain for a week until a second consultant discovered the cause.
The man, known as Mr C, was referred to Edinburgh Royal Infirmary by his GP in September 2010 after he began coughing up blood.
He was sent away several times but his GP persisted and he was finally diagnosed with throat cancer in September 2011.
Mr Martin said: “I am concerned that had Mr C’s GP practice not been so persistent in pursuing his case, his cancer could have been left undiagnosed until the prognosis for him was significantly worse.
“I am also concerned that the appropriate examination required to diagnose the cancer was not carried out, given that it was a simple one, involving careful examination of the mouth and tonsils with a tongue depressor.”
He ordered a serious clinical incident review, a review of procedures and an apology.
The woman, known as Ms C, was taken to Stirling Royal Infirmary emergency department in June 2011 complaining of back pain following a fall from a horse.
A consultant conducted a limited scan of her lower spine and diagnosed a fracture, but over a week later she was still in severe pain and a second consultant found another severe fracture further up the spine which the original consultant missed.
The Ombudsman said he is “extremely concerned” about the first consultant’s “failure to properly assess and investigate Ms C’s spinal injury”.
“The advice I have accepted is that consultant one made serious and basic mistakes,” he said.
“This raises questions about their competence, which the board needs to address as a matter of urgency.”
He added: “The evidence suggests systemic failures within and between the emergency department and the orthopaedic ward which may impact on the future care of patients with similar injuries.
“Had the healthcare professionals in the emergency department followed standard practice, then an X-ray of Ms C’s spine would have been carried out and the seriousness of her injury would have been identified much sooner.”
He ordered an audit of standards, appropriate action against the consultant and an apology.
The Ombudsman has also ordered review of procedures at NHS Ayrshire and Arran, which failed to adequately manage an 80-year-old’s multiple existing medical problems after he broke his hip in June 2011. He died two months later following several readmissions.