Hospital's administrative errors delayed scan

What happened

Ms Y saw an associate specialist in neurology, who thought her symptoms might have been caused by her existing medication. He referred her for a scan. The appointment letter did not reach Ms Y because of a mistake in her address in the Trust's computer system. This did not come to light until she saw the associate specialist again for a review in late 2011.

Ms Y had a scan in early 2012. Clinicians did not see anything abnormal on that scan. She went to A&E two and a half weeks later, with symptoms that were initially thought to be caused by a stroke. After more investigations, including another scan, staff found Ms Y had a cancer of the lymphatic system.

What we found

The care provided by the associate specialist was appropriate. Ms Y's symptoms did not suggest cancer, and he referred her for a scan.

Significant administrative and systems failures meant the associate specialist did not know that Ms Y had not had her scan appointment until later in 2011. We could not say whether these problems delayed the diagnosis of Ms Y's cancer. This was because her symptoms did not suggest that clinicians should look for a tumour in the base of the skull, where one was later found.

There were some shortcomings in Ms Y's care. Clinicians did not identify an abnormality in Ms Y's skull on the first scan. However, it was difficult to see on the scan. Doctors found the abnormality two weeks later, when they investigated further and reviewed the scan. It was unlikely that this two‑week delay had a major effect for Ms Y.

We partly upheld the complaint.

Putting it right

We were satisfied that the Trust had already taken action to improve its administrative systems, so we did not make any further recommendations.