NHS Borders has apologised to the family of a man over the quality of care he received after being treated for cancer of the tongue.
It follows an investigation by the Scottish Public Services Ombudsman (SPSO) which has upheld two complaints from the daughter of the patient who died in 2014.
The watchdog report explains that following radiotherapy treatment for his cancer, the patient – referred to as Mr A – received ongoing support from NHS Borders community dieticians and regular reviews at a joint cancer clinic in another health board area.
“He also received speech and language therapy [SALT] as part of the cancer clinic for about six months and was then referred back to NHS Borders for ongoing SALT care,” states the report.
“In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth.
“He was subsequently admitted to Borders General Hospital in June 2014 with weight loss, decreased ability to swallow and noisy breathing caused by a narrowed or obstructed airway.
“He underwent endo-tracheal intubation – insertion of a tube to maintain an open airway to the lungs – and was transferred to a different hospital. He passed away about 10 days later.”
The man’s daughter (referred to as Mrs C) complained about her father’s care during the year before his death.
“She raised concerns that clinicians failed to adequately respond to Mr A’s mouth pain, malnutrition and weight loss as well as infections in his mouth,” states the report. “Mrs C also raised concerns about communication during two hospital admissions [at the BGH in May and June, 2014].
The SPSO says it took independent expert advice during its probe: “We found that when Mr A’s SALT care was referred back to NHS Borders, the referral was not actioned properly which means he did not receive any SALT support for about a year until shortly before his final admission.
“We also found there were failings in communications during Mr A’s final hospital admission [in June 2014). However, we found no evidence Mr A was given incorrect information during his May, 2014, admission.”
SPSO has recommended that NHS Borders should “review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer”.
It also wants the health board to demonstrate actions taken to ensure SALT referrals are properly actioned in future and to show what steps are being taken to improve communication with patients and their families at the BGH.
Responding to the report yesterday, Erica Reid, director of hospital care with NHS Borders, said: “We have taken on board the recommendations from the SPSO report and actions have been taken so that similar experiences should be avoided in the future.
“The quality of care that Mr A received was unacceptable and not of the standard we expect for our patients. We are sincerely sorry for the effect this has had on both Mr A and his family.”