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London North West University Healthcare NHS Trust

P-002605 · Statement · Decision date: 29 May 2024 · View London North West University Healthcare NHS Trust scorecard
Complaint (AI summary)
Mr L complained the Trust failed to provide him with test results from a cancer referral, despite numerous attempts, causing him distress and agony.
Outcome (AI summary)
The ombudsman closed the complaint. They considered the Trust had already rectified the impact of its failings, so no further investigation was needed.

Full decision details

The Complaint

3. Mr L attended the Trust on numerous occasions between March 2023 and May 2023. This was following a two-week cancer referral from its A&E department on 13 January 2023. Mr L underwent several tests during this time.

4. Mr L complains the Trust failed to give him his test results from his CT colonoscopy and video capsule endoscopy, despite him trying numerous different methods to try to get these.

5. Mr L states the failure to give him the test results caused him distress and agony, due to the concerns surrounding cancer.

6. Mr L would like financial remedy from the Trust for his experience.

Background

7. Mr L was referred to London North West University NHS Trust down the two-week cancer pathway from its A&E department, due to episodes of bleeding. Mr L attended a clinic on 17 March 2023 who referred him for a gastroscopy, CT colonoscopy and a video capsule endoscopy.

8. A gastroscopy is a test involving a small camera which is passed in your mouth, down your throat and into your stomach. It is used to check inside a patients throat, food pipe and stomach to identify the possible cause of their symptoms.

9. A CT colonoscopy is a test which involves using radiation CT scanning to obtain an interior view of the colon and rectum. It uses a CT scanner to produce two and three dimensional images of the bowel. It is used to examine the colon and to detect any changes or abnormalities.

10. A video capsule endoscopy is a test which involves swallowing a small capsule, which contains both a camera and a light. This takes pictures as it travels through the patient and as it travels along their gut.

11. Mr L attended the hospital and underwent all three of the above tests. A follow up appointment was booked for Mr L in January 2024, almost 10 months after he was first placed on the two-week cancer pathway.

12. Mr L received the results for his gastroscopy. However, he never received the results for the CT colonoscopy and video capsule endoscopy. Mr L tells us he made numerous calls to the hospital and left voicemails with them to try and obtain these results, but this was unsuccessful, and they never got back to him.

13. Mr L complained to the Trust. In its first response to Mr L’s complaint, the Trust apologised for Mr L’s experience and acknowledged not knowing his test results caused him frustration and anxiety. It advised Mr L the appointment booked for January 2024 was an administrative error and confirmed his appointment had already been brought forward by the Trust to 8 September 2023.

14. The Trust unfortunately cancelled this appointment on 8 September 2023 due to the clinic being overbooked.

15. The Trust rebooked an appointment for Mr L on 8 December 2023, which Mr L was unable to attend due to being abroad. It does not appear Mr L has attended a follow up appointment since this cancellation.

Findings

18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having considered this, we have seen the Trust has already done enough to put right the impact of these events.

19. Mr L told us he was concerned he had cancer as he was referred down the two-week cancer pathway. As he had not received his test results, it caused him distress as he did not know whether he had untreated cancer.

20. In its first response to Mr L’s complaint, the Trust apologised for Mr L’s experience and acknowledged not knowing his test results caused him frustration and anxiety. It advised Mr L the appointment booked for January 2024 was an administrative error and confirmed his appointment had already been brought forward by the Trust to 8 September 2023.

21. The Trust went onto explain it is best practice to see patients in clinic to explain test results rather than just send clinical reports in the post. It said the Trust was experiencing capacity issues due to the impact of the pandemic which caused a significant backlog. The Trust explained it has since increased capacity, but this has not yet enabled them to return to optimal waiting times.

22. The Trust told Mr L they had reiterated to the administrative team they must escalate appointments such as his to a senior manager if the next appointment slot available is well over that clinically required.

23. On 8 September 2023, however, the Trust cancelled Mr L’s follow up appointment due to the clinic being overbooked. The Trust rebooked this appointment on 8 December 2023, which resulted in further delays. Unfortunately, Mr L was unable to attend this appointment due to personal circumstances. Mr L told us he has still not received his test results.

24. We understand the distress which this caused to Mr L, and we are sorry for the experience which he had.

25. In its final response to Mr L on 6 December 2023, the Trust acknowledged Mr L had not received his test results and apologised for the anxiety which this caused. The Trust did point out it sent a letter to both Mr L and his GP on 26 April 2023, which confirmed Mr L did not have cancer and as a result the Trust had removed him from the upper GI cancer pathway. This letter confirmed Mr L’s gastroscopy was normal apart from his known diverticulum.

26. The Trust also said in its letter in a clinic on 17 March 2023 it discussed with Mr L that his risk of bowel cancer was low and nothing of concern was found during a physical examination.

27. In this final response, the Trust confirmed they had found nothing of concern in Mr L’s CT colonoscopy and video capsule endoscopy.

28. Our NHS complaint standards say organisations should give fair and accountable responses to complaints. This means openly identifying when things have gone wrong, or where services have had an unfair impact on people. Our NHS complaint standards say organisations should offer a range of ways to put things right for people, including meaningful and sincere apologies and taking learning from complaints to continuously improve services.

29. Having reviewed all the evidence, we consider the Trust has acted in line with the NHS complaint standards. The Trust has acknowledged and apologised for the delays with Mr L’s appointment and the delays with him receiving his test results.

30. It has also addressed the administration department with regards to appointments being escalated when required. This shows the Trust has learned from the complaint and has taken appropriate action to improve services. This should prevent this from happening again.

31. We also consider the letter which was sent to Mr L after the clinic on 26 April 2023 provided Mr L some reassurance that he did not have upper GI cancer and his symptoms were likely due to his diverticular disease. However, we do recognise not receiving test results in this situation would provide some level of distress.

32. Mr L told us he would like financial remedy for the distress caused. Our guidance on financial remedy explains when we would decide a financial payment is appropriate to put things right. It says we would not think a payment is appropriate for cases at level one on our severity of injustice scale.

33. Our guidance explains when we would consider a case to be level one. It says that is when the person has experienced a low impact injustice and where the effect on the person complaining is of short duration and where there are no other adverse effects or ongoing wider impact.

34. We do not consider financial remedy is appropriate in this case. Mr L tells us the experience he had with the Trust has been distressing and we are sorry for how it has made him feel. Having thought about this carefully, we think the impact from what happened does not exceed level one of our severity of injustice scale. Therefore we will not be considering financial remedy any further.

35. Based on what we have explained here, we have decided the Trust has acted in line with our NHS Complaints Standards and guidance on financial remedy to put things right and improve. We will not consider this complaint further.

36. We recognise Mr L’s complaint is important to him. We are grateful to him for bringing it to us. We hope our explanations provide some reassurance to him the Trust has put things right, including steps to improve in future.

Our Decision

1. We have carefully considered Mr L’s complaint about London North West University Healthcare NHS Trust (the Trust). We understand Mr L’s experience with the Trust in being unable to obtain his test results was frustrating and distressing. We thank Mr L for bringing his complaint to us. We were sorry to hear about the circumstances that led him to approach us.

2. We have considered all available evidence carefully and we consider the Trust has put right the impact of failings. We have decided not to consider Mr L’s complaint further. We explain the reasons for our decision in this statement.

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