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Case ref:201700353
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Date:May 2018
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Body:Fife NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Miss C complained on behalf of her mother (Mrs B) about the care and treatment provided to her late father (Mr A) following his admission to Victoria Hospital with a painful hip. Mr A, who had prostate cancer, underwent a hip replacement. The oncology (cancer) consultant who had been caring for Mr A went on leave for a number of weeks. During this period a scan found that Mr A's cancer had spread and he was later admitted to a hospice where he died a short time later. Miss C complained about the care and treatment Mr A received following his admission to hospital. In particular, that Mr A had not been informed that his cancer had spread significantly and that his life expectancy was much shorter than he had previously thought.
We took independent advice from an oncology consultant. We found that, during the period Mr A's oncology consultant was on leave, there was no record of him being informed that his cancer had progressed significantly and that his life expectancy was reduced. We also found that the delay in referring Mr A to the oncology team and informing him of the progression of his cancer appeared to have been caused by a lack of senior oncology cover when Mr A's oncology consultant was on leave. However, we noted that had the oncology medical team been contacted earlier it would not have changed Mr A's management as there had been no further treatment available to him. We also found that, in terms of palliative care, there had been no impact on his management as he had continued with his medication. We upheld Miss C's complaint. Whilst we noted that the board had already accepted that there had been a delay in informing Mr A of his cancer progression and had apologised for this failing, we made a further recommendation.
Recommendations
What we said should change to put things right in future:
- If a consultant goes on leave there should be adequate supportive cover.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.