8. In June 2021 Miss A was diagnosed with MS. She was referred to the Trust for a lumbar puncture and more specialist care. The Trust carried this out between 5 and 7 July 2021. The results were available on 13 July, after the Trust had discharged Miss A. When the Trust discharged Miss A she asked for copies of her records so she could review them herself.
9. On 27 April 2022, Miss A read the report from her lumbar puncture, which the Trust had sent for further screening. In the results, she saw the screening had found neoplastic phenotype B cells (which can indicate a type of cancer that forms in B cells (a type of immune system cell)).
10. Miss A discussed these findings with her MS nurse who referred it to the Trust to review. The Trust contacted Miss A and apologised for not discussing or reviewing the test results at the time of the lumbar puncture.
11. Miss A then had additional tests to check if she had leukaemia. She told us she had to wait two weeks to find out the results of these tests, which were negative. Miss A says this worry at the time was incredibly distressing and caused her to feel depressed, anxious, and even suicidal. Miss A feels it was just ‘sheer luck’ she did not have cancer due to medication she was on for her MS actively reducing the level of her B cells. The delay had no clinical impact on Miss A.
12. Our Principles say where maladministration (fault) or poor service has led to injustice (a negative effect on someone) or hardship, public organisations should try to offer a remedy (way to put something right) that returns the person to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately.
13. There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial. An appropriate range of remedies can include an apology, explanation, and acknowledgement of responsibility.
14. The Trust has accepted it did not properly review Miss A’s test results. It apologised to Miss A and said it was to blame. We are satisfied the Trust’s apology is an appropriate remedy because it apologises, offers an explanation and accepts it was responsible for what went wrong.
15. Our Principles also say part of a remedy may be to make sure that changes are made to policies, procedures, systems, staff training or all of these to make sure the maladministration or poor service is not repeated. It is important for lessons to be learned and changes to be made.
16. The Trust said that after getting Miss A’s complaint it has made changes to reduce the risk of this happening again. It said her complaint highlighted a flaw in how it follows up on test results. Like when results come in after a patient has been discharged.
17. The old system meant the whole department was responsible for the test results, so there was no individual or team responsible for following up on results after discharge.
18. The Trust explained that individual teams and staff members are now responsible for test results to make sure they are tracked to the relevant people and actioned as appropriate. The Trust has also anonymised Miss A’s complaint to use as an example of what can go wrong if results are not handled correctly.
19. Miss A asked for service improvements as an outcome to her complaint. We consider the Trust has already made appropriate service improvements to stop this from happening again in line with our Principles.
20. Miss A wants the Trust to financially compensate her for what happened. We do not doubt that finding out the results yourself and knowing what these may mean would have been very distressing. Miss A had to wait two weeks to see if she had cancer. If the Trust had reviewed the lumbar puncture results in July 2021, when they were first available, she would likely have had to wait two weeks also to find out if she had cancer or not.
21. We can see additional stress and worry were caused by not knowing if cancer had gone undetected for ten months, as the results were not reviewed straight away. That worry, although distressing, happened once and lasted for two weeks until the results came back as negative.
22. Our guidance on financial remedy includes a severity of injustice scale which helps us consider financial recommendations in a consistent way. Level 1 of our scale describes injustices where we do not think a financial remedy is appropriate. This includes distress and similar emotional impact that a healthy adult would be expected to deal with on a regular basis, and which does not affect the person’s day-to-day functioning, or their ability to live a normal life, for a period of up to two weeks. We consider the impact on Miss A here is likely at level 1 of our scale.
23. Overall we consider the Trust has done enough to put things right for Miss A. It has investigated Miss A’s concerns, accepted it was at fault and apologised for the distress this caused her. It accepted there were problems in how it was processing test results and made positive changes to reduce the chances of this happening again. Because of this, we are not asking the Trust to do anything more.
24. We are grateful to Miss A for bringing her complaint to us. We are sorry to hear about what happened and we hope she can take some reassurance from the positive steps the Trust has taken because of her complaint.