-
Case ref:201902648
-
Date:July 2020
-
Body:Grampian NHS Board
-
Sector:Health
-
Outcome:Some upheld, recommendations
-
Subject:clinical treatment / diagnosis
Summary
C was referred to the board's plastic surgery department with a suspected sebaceous cyst (a common non-cancerous cyst of the skin) as a routine referral. It was found that C had a squamous cell carcinoma (a type of skin cancer). After diagnosis of the cancer C subsequently underwent treatment to remove it. After surgery the board's district and community nurses managed C's wound in the community. C complained about the treatment provided by the board and subsequent wound care.
We took independent advice from a consultant plastic surgeon. We found that the board's investigation, diagnosis and treatment of C was reasonable and met the waiting times specified by the Scottish Government in 'Better Cancer Care, An Action Plan'. While there had been some communication failings, the treatment provided was reasonable. We did not uphold this aspect of C's complaint.
We took independent advice from a nurse regarding C's wound care. We found that the wound care provided by the board was unreasonable. It was not evidenced that C's wound had been seen and assessed by an appropriate clinician before agreeing how the wound would be cared for. The board accepted there was a lack of documentation relating to C's wound care. We upheld this aspect of C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for failing to provide reasonable wound care to them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- Wounds should be assessed by an appropriate clinician before determining the best course of treatment.
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.