The unnamed medical practice has been told to apologise to the patient’s spouse and implement several changes (stock image).
Doctors missed “red flag” symptoms in a patient who later died from cancer, a report has ruled.
A Highland medical practice, which has not been named, has now been ordered to apologise to the patient’s bereaved spouse and told to implement several recommendations following the incident.
The Scottish Public Service Ombudsman (SPSO) issued its ruling after the spouse complained about the care and treatment given to their late partner – referred to only as ‘A’ in the report.
The bereaved spouse – dubbed ‘C’ in reports – complained about the treatment given to ‘A’ by the unnamed practice before they died from metastatic renal cancer.
‘C’ also raised concerns that ‘A’ was misdiagnosed by the practice and that they were not referred for further medical investigation when they should have been.
In its findings, the SPSO said that the medical practice had provided a detailed timeline of appointments, symptoms, treatments, and actions taken, and that patient ‘A’ had a complicated medical history. The practice also argued that because ‘A’ had found it difficult to attend face-to-face appointments, this had made it difficult for doctors to assess the level of pain they were in.
But the medical practice also acknowledged that there was “some miscommunication” between the practice and secondary care colleagues in physiotherapy.
Issuing its findings, the SPSO said that although “much of the care and treatment provided to ‘A’ had been reasonable” it also found that that “some consultations were unreasonable, and that red-flags were not always appropriately identified and/or recorded and were not followed up”.
It continued: “We also found that the SAER was not completed in line with the guidelines. As such, we upheld both complaints.”
As well as telling the practice to apologise to ‘C’ “for the failures identified”, it also listed areas for action to ensure such incidents are not repeated.
It told the practice to begin a monthly meeting with professionals to discuss patients with complex medical presentations, and to hold gold standard meetings monthly including the clinical team, district nurses, and MacMillan nurses. Learning points from the SAER that was carried out should also be identified.
It added: “Documentation of consultations, examinations carried out, and the points raised and discussed should be accurate and complete.
“Treatment should be in line with the relevant NICE guidelines specifically in reference to red-flag symptoms and signs. Clinicians should take action to identify if any red-flag symptoms are present and take appropriate action when they are.
“Patients should be escalated/ referred to hospital pathways when their presentation indicates it is appropriate. Communication and interactions with other health care teams should be carried out reasonably and effectively.
“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.”
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