Diagnosis
21. Mr O says following a CT scan at the Trust in June 2017, the clinic letter sent to his GP omitted important information on whether he had emphysema or not. He says this affected his treatment from that point onwards.
22. Mr O says he found out about the error within the clinic letter during a consultation with another respiratory specialist in Ireland in March/April 2019.
23. The Trust said the CT scan reported: ‘a 13 mm right apical bleb is seen. No emphysema elsewhere’. However, the clinic letter sent to Mr O’s GP, dated 28 June 2017, said: ‘a 13mm right apical bleb, no emphysema’. It explained the omitted word ‘elsewhere’ in the clinic letter could give rise to a different interpretation of the CT findings.
24. As a result of Mr O’s complaint, the Trust reviewed the CT scan taken in April 2017 and confirmed the diagnosis of a 13 mm right apical bleb and no emphysema elsewhere. It also confirmed the bleb seen on the scan is emphysema.
25. The evidence shows the Trust also carried out an investigation to see how the error within the letter to Mr O and his GP was made. The original dictation of the letter could not be checked as these are erased after a 90-day period. It is therefore not possible to confirm the word ‘elsewhere’ was in the original dictation or whether the letter was typed correctly or incorrectly.
26. The Trust acknowledged that after the letter was returned from typing, the respiratory consultant checked and made changes prior to it being issued. It recognised any incorrect information should have been identified and changed before the letter being sent out.
27. The relevant guidance is the General Medical Council (GMC): Good medical practice. This says:
‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible’.
28. Based on the available evidence it is not possible to determine whether the omission of the word ‘elsewhere’ was in original dictation or whether the letter was typed incorrectly. However, the evidence shows the respiratory consultant checked the letter prior to being sent to Mr O’s GP. We therefore consider the Trust’s respiratory consultant should have ensured information in the letter was accurate before it was posted, in line with GMC guidance. This is a failing on the part of the Trust.
Impact:
29. As a result of the Trust’s actions Mr O says his GP reduced his corticosteroid inhaler dosage. Corticosteroids inhaler, often known as steroids, are an anti-inflammatory sprays or powders that you breathe in. They are mainly used to treat asthma and chronic obstructive pulmonary diseases (COPD). Mr O says he developed a more severe cough and increased breathlessness. He explains the stress of the situation affected his ability to deal with his COPD.
30. The relevant guidance is UpToDate: Treatment of primary spontaneous pneumothorax (PSP) in adults. This states that where there is recurrence of a pneumothorax, definitive intervention to prevent recurrence should be considered.
31. Our adviser said the scan shows a subpleural bleb at the extreme right apex of the lung, but there is no widespread emphysema elsewhere and no evidence of bullous disease - a respiratory distress caused by COPD. Mr O’s function was assessed by spirometry in June 2017. This was reported as normal, indicating no moderate or severe COPD – of which emphysema can be a part of.
32. The presence of mild emphysema on the CT would not have changed the Trust’s planned management. Our adviser said the correct plan in the event of two spontaneous pneumothoraxes’ would be for the patient to be referred to a thoracic surgeon to discuss the benefits and disadvantages of having a procedure performed to prevent further events. This is either pleurectomy or pleurodesis. Pleurectomy is a procedure to remove the lining between the lungs and the chest wall. Pleurodesis involves the introduction of liquid medication into the space between the lungs and the chest wall to prevent further fluid or air leaking out from the lung. The Trust made a referral to the thoracic department at UHB for consideration of preventative surgery, in line with the UpToDate: PSP in adults.
33. Mr O’s GP records show the GP reduced his corticosteroid inhaler dosage treatment in November 2017. Our adviser said this was because Mr O was showing no symptoms on high dose treatment. The GP recorded Mr O had no chest tightness, no breathlessness, wheeze or cough present at the time. He was not using his short-acting Beta Agonist (SABA) inhaler as Mr O felt there was no need. SABA inhaler provides quick relief of asthma symptoms.
34. In making the decision to reduce the dosage, the GP referred to BTS/SIGN: British Guideline on the Management of Asthma within the consultation. These guidelines describe a section on the importance of step down of therapy when no symptoms are indicated – as it was at this time for Mr O. Our adviser said the finding of emphysema would not have altered the inhaled therapy he was being prescribed, nor would it have changed the chances of reduction of the treatment by the GP. There is no relationship between the events surrounding the operative tests/referral for pneumothorax, and the reduction in treatment by his GP.
35. Based on the evidence, we cannot say the missing information in the June 2017 clinic letter affected Mr O’s treatment with the Trust or caused the GP to reduce his asthma medication. However, we understand that finding out about the error would have caused Mr O confusion and distress.
Outcome:
36. Mr O wants an apology and service improvements.
37. On finding out about the omission in 2019, the Trust carried out a thorough investigation into how this error occurred. Based on the evidence, this was a one-off failure to appropriately check a clinic letter before it was issued. There is no evidence of adverse effects or ongoing wider impact. The Trust has apologised for the omission, the impact this may have caused Mr O and provided a reasonable explanation of how this error occurred. The Trust fed back to the consultant concerned and the Trust’s clinical service lead to minimise the risk of this happening again. We consider this is reasonable action to put matters right, in line with our Principles for Remedy (our Principles). This says an appropriate remedy would include:
• An apology, explanation and acknowledgement of responsibility • Remedial action, which may include staff training.
Follow up referral
38. The Trust referred Mr O to UHB’s Thoracic Department in June 2017. He received a letter from UHB in late 2017, saying his first appointment in January 2018 had to be cancelled due to unforeseen circumstances. During the complaint process in 2019, the Trust claimed Mr O did not follow up a referral for thoracic surgery. Mr O is unhappy with this statement which he says is not true.
39. The Trust said it is unfortunate the thoracic surgical appointment offered to Mr O was cancelled. It acknowledged it incorrectly suggested it was Mr O who did not follow up a referral to the thoracic department at UHB for his first appointment, in its letter dated 30 July 2019. This is a failing.
40. Within its complaint response, the Trust apologised for making this suggestion.
41. We understand the frustration this may have caused Mr O. However, in line with our Principles, we consider the Trust’s letter of apology is reasonable action in putting matters right. On that basis we do not uphold this complaint.