Care complaint upheld against Lorn Medical Centre

The family of an Oban woman who died after her returned cancer was missed have received a second apology for NHS failings - this time from Lorn Medical Centre in Oban.

 

Margaret Johnstone's family told The Oban Times the last six months of  the 67-year-old's life were 'horrendous' and it was difficult to remember all the good times spent with her because of what happened.

 

A letter sent to Mrs Johnstone's family on behalf of the medical centre in Soroba Road, included an apology for the delay in sending an urgent referral letter after her symptoms, at first considered to be related to Irritable Bowel Syndrome, worsened.

 

An investigation by the Scottish Public Services Ombudsman (SPSO) found in December last year that the medical practice failed to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending a suspicion-of-cancer letter.

 

The practice requested a review of the decision but the Ombudsman decided that it would remain unchanged.

 

Lorn Medical Centre sent its apology on January 18 this year, saying: "We wish to apologise again for the failings identified in the care we provided Margaret...and know she will remain a huge loss in all your lives".

 

That apology follows one from NHS Highland in 2022 after the health board was found by the Ombudsman to have missed Mrs Johnstone's cancer symptoms despite multiple  admissions to Lorn & The Islands Hospital.

 

Both complaints were taken separately to SPSO-level by Mrs Johnstone's sister Mary Young.

 

The decision notice upholding the complaint against Lorn Medical Centre read: "A (Mrs Johnstone) had previously been diagnosed with breast cancer a number of years ago. 'A' became ill and attended the practice on several occasions over the year. The GP considered 'A' had gastroenteritis.  'A’s symptoms persisted and 'A' was referred to hospital for a colonoscopy. The request was rejected. 'A' presented at the practice with the same symptoms on two further occasions and the practice made an urgent suspicion of cancer referral to the health board."

 

Mrs Young complained that despite her sister's multiple attendances at the practice and concerns that the cancer had returned, the practice failed to reasonably respond to her worsening condition and delayed or failed in carrying out appropriate investigations and associated tasks.

 

The Ombudsman's findings said: "We took independent advice from a GP adviser. We found that initially there was no unreasonable delay in the practice recognising the seriousness of 'A’s symptoms and that the appropriate referrals for a colonoscopy and ultrasound scan were made. We also noted that it would not have been appropriate for the practice to have undertaken a Carcinoembryonic Antigen Test, a blood test used to help diagnose and manage certain types of cancers.

 

"However, we found that there was a failure to include clinically important information in referrals and in consultation documentation, and that there was a delay in sending 'A’s suspicion of cancer letter. We also found that the practice should have considered undertaking some additional blood tests when it was clear 'A' was deteriorating, or documented the awareness of any blood tests undertaken by the hospital during this period. Therefore, on balance, we upheld the complaint."

 

It was only when Mrs Johnstone went private to get a scan in England that a tumour showed up and her cancer was diagnosed. She died in November 2020.

 

Mrs Young told The Oban Times: "The frustration and anger has almost gone, but the pain of losing Margaret will never leave us. It was awful that Margaret did not get the care that she should have received. The formal notification of the Ombudsman's decision was definitive, the heading on it said that Lorn Medical Centre failed to provide Margaret with reasonable care.

 

"The last six months of her life were horrendous. It’s difficult to remember all the good times the family had with Margaret because of what happened.

 

"We can only hope that these changes recommended by the Ombudsman will be made and that those changes will help other people's loved ones to be looked after the way they should be.

 

"As a family we feel we are just a tiny drop in the ocean. I feel we have been listened to by the Ombudsman but will it really make much difference? This scenario should never have happened in the first place.

 

"It is vitally important that families and patients speak up if they feel they are not getting the right care and not being listened to."

 

Lorn Medical Centre was asked by the SPSO to apologise for the failings identified in respect of the complaint.

 

The medical centre's apology informed Mrs Johnstone's family that the Ombudsman's recommendations have now been discussed at length at several practice meetings and that the recommended timeframes for sending referral letters are being met in recent months.

 

The practice manager and senior partner have also met with the Ombudsman and two senior members of her staff to discuss Mrs Johnstone's case and the recommendations made.

 

To put things right in future, the SPSO said appropriate and timely blood tests should be considered when it is clear a patient is deteriorating in cases similar to Mrs Johnstone's, or awareness of any blood tests undertaken - for example by the hospital - are documented.

 

Notes of consultations should include appropriate detail including a description of the length and progression of symptoms along with any potentially relevant past history.

 

And referral letters should also include a clear history, examination and relevant background information.

 

Practice manager Mark Dixon said this week: "The Lorn Medical Centre wish to express their sympathy to the family concerned for their loss. Due to confidentiality, we are unable to comment further. We would like to provide reassurance that we are committed to providing a high standard of care for our patients and have complied fully with the Ombudsman’s recommendations."