Home > Publications > Selected Cases - Health >
Selected Investigations Completed December 2000March 2001 > Part I, Case no. E.2266/99-00
Complaint against: West Suffolk Hospital NHS Trust
Summary of case
In November 1998 Mr T’s GP referred him to an oncologist. On 7 December Mr T was admitted to West Suffolk Hospital (the first hospital) and a CT scan of his abdomen suggested he had a lymphoma. A CT-guided biopsy was undertaken the following week to establish the sub-type of lymphoma. Mr T was discharged and told that treatment could not begin until the results of the biopsy were known, but he was told that that would be within the next four days. However, by 30 December a definitive diagnosis had still not been forthcoming and treatment had not commenced. Furthermore, Mr T’s condition had deteriorated and he was re-admitted. A consultant physician responsible for his care said that she would send his biopsy specimen to a cancer centre at another trust (the second hospital) for a second opinion. Mr T became increasingly unwell and he was transferred to the second hospital on 31 December; his lymphoma was sub-typed by the second hospital that day and treatment commenced on 4 January 1999; Mr T died on 21 January. Mrs T subsequently learned that the consultant physician was not qualified to diagnose or treat lymphoma. She complained to the Ombudsman that the Trust had not provided a sufficiently rapid and co-ordinated specialist diagnosis and management of her husband’s condition.
Findings
In reaching his findings the Ombudsman took clinical advice from two independent professional assessors. The Ombudsman found a serious lack of co-ordination in Mr T’s care. Mr T’s GP suspected lymphoma in November and made an appropriate referral to oncology. The assessors said that, as such, Mr T’s case merited urgent, co-ordinated specialist care from the outset. However, his care was transferred from oncology to the consultant physician’s team while the results of the biopsy were awaited. The assessors said that the biopsy should have been carried out sooner and treatment commenced. The consultant physician did not have expertise in the treatment of lymphoma and the assessors said that a clinician with specialist expertise might have taken more urgent action; a specialist would have known that sufficient information was available to start chemotherapy and that that would have offered a 60% chance of remission with a 30-40% chance of complete cure.
A locum haematologist (the haematologist) was aware that there was a problem obtaining a definitive diagnosis, but he was unwilling to commence treatment without that diagnosis. The assessors criticised him for that, and for the lack of urgency with which Mr T’s case was handled. In their opinion, the haematologist should have taken the lead in Mr T’s care and could have considered transferring him to the second hospital sooner. The Ombudsman recognised the difficulties that the haematologist was experiencing at the time, as a locum member of staff, but he was concerned at the lack of urgency. The Ombudsman agreed with the assessors that Mr T should have been transferred to the second hospital sooner, given that staff there had the capability of making a rapid diagnosis. He upheld Mrs T’s complaint.
Remedy
The Trust apologised to Mrs T for the shortcomings identified and agreed to ensure that their referral policy highlighted the importance of early specialist co-ordination in cases of clinical urgency and to remind medical staff of the need to maintain adequate clinical records. The Trust also agreed to consider how they might monitor that more closely and ensure that locums were encouraged to voice their concerns about the limitations of the service they were able to provide.
Previous < Contents > Next
|
