A Fife GP surgery has been urged to meet grieving parents to apologise for failings in the care of their late six-year-old son.
A mother, known only as Mrs C, raised serious concerns about the care her son received at the medical practice in 2011.
She said the practice, which has not been named, failed to provide her son with appropriate clinical treatment and that there had been an unreasonable delay in referring him to a specialist.
Until that point the youngster had only visited the practice three times for childhood infections but in 2011 he had 19 medical contacts 13 at the practice.
She told the Scottish public services ombudsman her son had been seen a number of times for weight loss, pain in his bones, nausea, fatigue and vomiting.
He was seen by various GPs and several tests were carried out. He was referred to Ninewells Hospital in July and was given an appointment in September.
His mother pressed for an earlier appointment and he was seen in August before being admitted to the Royal Hospital for Sick Children in Edinburgh, where he was diagnosed with stage four Burkitt’s lymphoma a form of the cancer non-Hodgkin lymphoma.
He died just months later in May 2012.
The practice analysed his case and said they had found it very difficult to diagnose and that they would “have difficulty managing things differently”, although they apologised for an element of his treatment.
The ombudsman looked to the National Institute for Health and Clinical Excellence guidelines for cancer warning signs.
It states there should be an urgent referral where there is no clear diagnosis after about three visits with the same problem. It also includes a list of symptoms “which Master A clearly had”.
An independent adviser said alongside the increase in GP visits, medical records suggested doctors should have viewed his symptoms with a higher degree of suspicion.
The adviser, a GP, said there had been a failure to repeat blood tests and the hospital referral was marked “routine” not “urgent”.
“She was concerned that the practice has said that they would not, in hindsight, have managed Master A’s condition differently.
“She took the view they had failed to provide a reasonable standard of care for him.”
The ombudsman noted the practice had based treatment on the fact the hospital had confirmed the GPs’ diagnosis of gastritis.
“My adviser said this view had some validity, but also noted that after going to hospital Master A was in further contact with the practice five times, with similar worrying symptoms.”
The adviser felt the practice should have recognised their significance.
The ombudsman upheld Mrs C’s complaints and recommended the practice write to her and her husband to apologise and offer to meet with them to reinforce this.
He also asked for evidence the practice had discussed the case with all the GPs involved as a learning tool.
A spokesman for NHS Fife said GPs were independent contractors so it would be inappropriate for them to comment on a complaint relating to an individual practice.
However, medical director for primary care, Dr Stella-Anne Clarke, said: “NHS Fife takes all complaints seriously and findings and recommendations made by the ombudsman in every case are always shared so that lessons can be learned by all.”