NHS Highland apologise over care of learning disabled woman who died from brain tumour

By The Press Association24th November 2016News ScotlandCare Standards, Highlands, Learning Disabilities, News Scotland, NHS, Vulnerable Adults

A health board has apologised after a woman died from a brain tumour six days before an MRI scan.

An investigation by the Scottish Public Services Ombudsman (SPSO) found several failings in NHS Highland’s handling of the case.

The health board said it was “truly sorry” and would be writing to the woman’s family to offer its “sincere apologies”.

The woman, who had physical disabilities, learning difficulties, autism, chronic fatigue syndrome and asthma, first complained of headaches in December 2013.

She had surgery to remove a nasal ulcer on February 12, 2014 and a CT scan carried out that July showed no abnormality of her sinuses.

From July 30, 2014 onwards, the woman, referred to as Ms A, attended her medical practice on a number of occasions complaining of vomiting and headaches

In August that year, Ms A’s mother contacted NHS 24 several times with concerns about her headaches and vomiting.

She was admitted to Raigmore Hospital (pictured) in Inverness with abdominal pain on August 12, 2014 and was diagnosed with occipital nerve compression.

Following her discharge from hospital, Ms A was given an appointment for an MRI scan on September 8, but she died at home on September 2.

A post-mortem examination found the cause of death was a haemangioblastoma, a tumour of the central nervous system within the brain.

One of the Ombudsman’s advisers, a GP, found the practice failed to recognise the significance of “red flag signs” that could have indicated a brain tumour and the need for urgent referral from July 30, 2014 onwards.

Another adviser, a neurosurgeon, said there is “no doubt that if the tumour had been discovered in July or early August, it would have been operable”.

The neurosurgeon also said the tumour was benign and curable, and if Ms A had been operated on there would have been a 90% chance of a full recovery.

SPSO launched its investigation following a complaint made on behalf of Ms A’s parents.

It found the practice did not provide a reasonable standard of care in relation to the examination and referral of Ms A’s headache symptoms, and the board’s out-of-hours service failed to provide Ms A with appropriate care and treatment.

Regarding Ms A’s admission to hospital, the Ombudsman found failings in relation to the neurological examination recorded and a failure to review a CT scan of her sinuses.

SPSO was also critical of the way the board handled the complaint and its “lack of focus on their failings and ways to improve their services”.

The Ombudsman made several recommendations, including that the board and practice should apologise to the family.

An NHS Highland spokesman said: “We are truly sorry for the standards in the care and treatment provided to this patient and will be writing to the family offering our sincere apologies.

“We accept the findings of the report and it has been shared with staff and senior managers. We will also be conducting a significant adverse event review, which will be chaired by a senior doctor.

“This will involve analysing the clinical care and treatment provided in order to learn and implement improvements in our practice. The family will also be kept up to date on this process.”