The Scottish Public Service Ombudsman (SPSO) has ruled in favour of a woman who waited an “unreasonable” time to be referred to hospital with a breast lump.
In a report published today, the ombudsman said the referral should not only have been made immediately, it should have been marked as “urgent”.
The report does not reveal the name of the medical practice at fault, simply identifying it as a practice in the NHS Grampian area.
The person at the centre of the complaint has since been treated for cancer.
Referral not marked as ‘urgent’
The report said: “C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast.
“We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable.
“It was also unreasonable that the referral was not marked as urgent.”
The SPSO said the medical practice has accepted there was a “complete systems failure in the care and treatment provided to A”.
The report continued: “Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff.
“We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint.
“In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent.
“We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case.
“Therefore, we upheld C’s complaint.”
Told to apologise
The medical practice was asked to apologise.
The SPSO said that patients should receive appropriate assessment and referral in line with relevant guidelines. Patient referrals should be reviewed and actioned when the responsible member of staff is absent unexpectedly.
It added: “Where appropriate, patients should be contacted after receiving a significant diagnosis.
“This should include when the practice become aware that harm has occurred as a result of an unintended incident in healthcare to take into account duty of candour responsibilities, individual roles and their role responsibilities in making sure this happens.”
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