NHS Lanarkshire apologises over cancer death failures
A health board has apologised to the family of a woman who died of cancer over multiple failures in how medics dealt with her case.
The 54-year-old attended Hairmyres Hospital in East Kilbride after feeling unwell and was given the all-clear.
She later learned she had cancer and died while awaiting an appointment.
A watchdog found NHS Lanarkshire had "unreasonably delayed" informing the woman of her diagnosis and in offering an oncology appointment.
The Scottish Public Services Ombudsman was asked to investigate complaints made by the woman's sister.
It noted the woman (Ms A) had a past medical history of breast cancer and attended Hairmyres Hospital several years later after experiencing "breathlessness and abdominal pains".
During the appointment a chest x-ray was taken and Ms A was given the all clear and discharged home.
She returned to the hospital three weeks later after continuing to feel unwell and was given a CAT scan, which showed her breast cancer had returned and spread.
Following Ms A's death, her sister (Ms C) asked NHS Lanarkshire to re-check the chest x-ray from her first visit to Hairmyres.
The health board told Ms C that both a chest x-ray and a lumbar spine x-ray were carried out during that admission.
While the chest x-ray was clear, the lumbar spine x-ray was positive for spinal metastatic disease, showing that Ms A's cancer had returned and spread to her spine.
NHS Lanarkshire said it was unsure if this was communicated to Ms A at the time.
Following an investigation, the ombudsman said: "I have concluded that the three week delay in Ms A's diagnosis was caused by the board's failure to note the abnormalities in the lumbar spine x-ray taken during Ms A's admission.
The ombudsman continued: "I am critical that a scan showing a positive result of cancer was entirely missed.
"While Ms A's cancer was diagnosed three weeks later, this was due solely to Ms A's perseverance in seeking treatment for her symptoms.
"Had Ms A not sought further investigation, the delay in diagnosis could have continued indefinitely."
The ombudsman also expressed concern at "the failure of board staff properly to investigate the missed scan when it was brought to their attention by Ms C's complaint".
"This information was easily available from the A&E records, but the complaints investigators do not appear to have checked these records, or sought comments from the A&E clinician who reviewed the scan," the ombudsman said.
The report concluded: "I have recommended that the board apologise to Ms C for the failings my investigation found.
"I have also recommended that the board undertake a specific internal investigation into the actions of staff in this case, to determine why the results of the lumbar spine x-ray were missed by both A&E staff and radiology, and to identify process improvements to ensure this does not reoccur."
Rosemary Lyness, NHS Lanarkshire's director of nursing, said: "We would like to take this opportunity to apologise to the patient's sister and her family for failing to provide the level of care she should have received.
"We have fully accepted the recommendations contained within the ombudsman's report.
"We have already undertaken a full review of the complaints process and we will develop an action plan to address the areas highlighted within the report and to ensure that lessons learned are shared across NHS Lanarkshire."