NHS Tayside has been criticised for a repeated failure to diagnose the ovarian cancer of a young woman who died from the disease.
The Scottish public services ombudsman ordered the board to apologise to the woman’s family and review the way patients are referred back to their GP.
The woman described only as Ms A who was in her early 30s suffered increasing back pain over a two-month period but Ninewells Hospital kept sending her back to see her own doctor.
She had a scan at Ninewells which was reported as normal but when her pain worsened she went to the hospital’s accident and emergency department.
Its “three day guideline” meant patients with injuries or illnesses for more than three days who have already seen their GPs should be referred back.
The woman’s GP made an urgent referral to the orthopaedic/physiotherapy clinic at Ninewells but a consultant downgraded it to routine and again nothing was found.
The woman lost a lot of weight but because of the scan result this wasn’t considered to be a danger sign.
A week later the neurology clinic told her to continue the treatment she was on. Eight days later, after her GP again referred her to the hospital, her original scan was reviewed and an abnormality was found.
She was diagnosed with advanced ovarian cancer and died four months later.
Her sister lodged an official, complaint which ombudsman Jim Martin upheld.
Advanced ovarian cancer is rare in a woman of the age of the patient concerned, but the abnormality in the initial scan was conspicuous.
Mr Martin said reliance on the mis-reported scan appeared to have influenced later treatment and contributed to the delay in diagnosis.
“Over a relatively short time, Ms A became almost unable to walk, and hospital clinicians who saw her did not appear to take account of her increasingly painful symptoms,” he stated. “Her GP did and continued to press for a diagnosis.”
NHS Tayside later held a Critical Incident Review of her care and treatment but her sister complained that the health authority did not provide the family with a copy of the report.
NHS Tayside medical director Dr Andrew Russell said the board have apologised to the family and extended their deepest sympathies.
“We accept all the recommendations in this report and have already taken appropriate actions to address the areas highlighted,” he added.