A cancer patient died three weeks after being diagnosed with a rare form of the disease that was missed by medics.
NHS Lanarkshire has been ordered to apologise to the family of the patient after it "missed opportunities" to carry out vital tests at University Hospital Monklands in Airdrie.
The patient had been admitted to the hospital on multiple occasions having been ill for around five months.
Doctors failed to test fluid around their lungs until eight weeks later, an investigation has found, reports the Daily Record.
When the results came back as inconclusive, staff should have carried out a biopsy, however, this was not done.
A scan of their abdomen revealed more fluid, which also should have been tested, but this test was also not carried out.
A keyhole biopsy into their pleural space - chest cavity - was eventually performed 14 weeks later with the results showing the patient had a rare form of cancer.
NHS Lanarkshire has been told to apologise to the person’s family and to adhere to national guidelines on managing pleural disease.
The SPSO said: “We found that A's case was complex and unusual and that it was reasonable to consider other diagnoses more likely than cancer, and to treat these accordingly while investigations continued.
“However, we found that reasonable action was not taken to manage the pleural effusions (fluid around the lung) that A initially presented with.
“Guidelines indicate that a fluid aspiration (removal of a small amount of fluid for testing) should have been arranged to rule out infection in the pleural space (cavity between lungs and chest wall).
“This was not arranged until almost eight weeks later.
“When this was done and the result was inconclusive, guidelines recommended that a biopsy be carried out and this wasn't done either.
“In addition, an ultrasound scan the following day reported ascites (fluid within the abdomen), and again a fluid aspiration was indicated but wasn't carried out.
“A biopsy via thoracoscopy (keyhole camera into the pleural space) was not carried out until a further 14 weeks later. A's cancer was diagnosed thereafter.
“We found that there were earlier indications for a thoracoscopy and missed opportunities to diagnose A's cancer from the time of their initial presentation.
“While we acknowledged that an earlier diagnosis was unlikely to have altered A's prognosis, we noted it would have enabled palliative care to commence and allowed the family time to prepare and make the most of the time they had left together.
“We upheld this complaint.”
Judith Park, NHS Lanarkshire director of acute services, said: “Our thoughts and sympathies remain with the family.
"We very much regret any instance where we have failed to provide the highest standards of care for our patients and offer our sincere apologies for any failings in the care of this patient.
“We have fully accepted the recommendations within the Ombudsman’s reports and the lessons learned will be shared to help avoid similar occurrences in future.”
