East Ayrshire health bosses apologize for ‘failures’ in tragic treatment of cancer patient

Senior Officers of the East Ayrshire Health and Social Care Partnership have apologized to the family of a cancer patient who died after ‘failures’ were made in monitoring their treatment at a local doctor’s office .

The Scottish Public Services Ombudsman (SPSO) upheld a complaint against the NHS Ayrshire & Arran by the spouse of the deceased patient.

Now the bosses of the partnership have admitted that they “failed to meet” the high standards they “strive for” in relation to the tragedy, which saw blood test results “outside the normal range. “pass” unrecognized “.

Essentially, earlier action should have been taken when blood test results were known and then compared to the patient’s history and symptoms.

The patient, known only as “A” and his spouse, known only as “C” have not been identified.

The location of the medical practice has not been disclosed, but it is within the NHS limits of Ayrshire and Arran.



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In its report, the SPSO said: “C complained that the firm failed to take reasonable action in response to the symptoms and condition of her late spouse (A).

“A had a long history of degenerative disc disease affecting her spine (when normal changes that occur in the discs in your spine cause pain) and a history of stomach cancer.

“A visited or contacted the practice several times in three months regarding neck and shoulder pain, numbness in right hand and twitching in right leg.

“Tests were carried out, drugs and therapies prescribed and a referral to an orthopedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system) was made.

“After a fall at home, A was admitted to a hospital where A was diagnosed with spreading cancer to A’s spine.”

The report goes on to say that the patient died, prompting her spouse to complain about the doctor’s office response to symptoms and A’s condition in the previous months.

The report states: “In response, the practice recounted the actions it had taken in response to A’s visits and contacts during her final months, found blood tests the results of which showed no evidence. significant abnormality or spread of cancer and explained that A’s symptoms were related to their ongoing diagnosis of degenerative cervical disc and spinal stenosis (a condition where the space around the spinal cord narrows, compressing a section of nerve tissue ).

“Practice has indicated that an important case review has been carried out. This had highlighted that A’s orthopedic orientation could have been upgraded to an emergency when it was clear A’s symptoms were not being controlled, but said it was doubtful that this had an impact on the result. C was not satisfied with this response and filed his complaint with this office.

During the SPSO investigation, they sought independent advice from a general practitioner.

An excerpt from the report reads: “We found that the firm was taking reasonable steps in response to A’s symptoms and condition – to some extent. However, when it became evident that A’s symptoms were not being controlled and started to get worse, the practice’s actions were unreasonable.

“We found that the potential significance of the test results reported to the office and the potential link to A’s symptoms were not reasonably recognized by the office until they reviewed A’s care and treatment at the office. following our investigation of the case.

“Therefore, we upheld C.

“However, although we noted that earlier practice action may have led to an earlier admission to hospital, it was extremely unlikely that it prevented A’s death.”

The medical practice at the center of the case has now been ordered to “revise” the way it treats blood samples that are “considerably outside the normal range.”

Craig McArthur, Director of the East Ayrshire Health and Social Services Partnership, said: ‘I am sorry we did not meet the high standards of care that we seek in the NHS Ayrshire & Arran for this patient, and I offer my deepest condolences to their families.

“In addition to a formal apology to A’s spouse, I can inform you that the GP practice has fully accepted all of the recommendations of the Scottish Public Services Ombudsman (SPSO) report.

“The practice of the general practitioner has resolved the identified issues and made the appropriate changes in terms of ensuring that all blood results are effectively communicated to patients, record keeping and required follow-up actions are carried out to required standards. and reviewing home visiting policies that have been updated in accordance with required guidelines.

He added, “To ensure learning across the organization, we will share the findings of the report with staff and reassurance to our clinical governance teams that the necessary actions have been taken. “

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