A Lanarkshire patient who died shortly after being diagnosed with a rare cancer "would have lived longer" if tests had not been delayed and results sent to the wrong consultant, a damning report has concluded.
It took almost seven months to carry out investigations when a "reasonable time" would have been 12 weeks.
The patient was diagnosed with primary biliary cirrhosis (PBC), which reduces liver function, in 2004 and was under the care of gastroenterologists in NHS Lanarkshire.
An inquiry by the Scottish Public Services Ombudsman (SPSO) found that the patient's PBC was "not well controlled" and they had developed signs of disease progression.
However, it took clinicians at NHS Lanarkshire 27 weeks to carry out the necessary investigations and there was a further delay when the results were sent to the wrong consultant.
The patient was diagnosed with cholangiocarcinoma, a rare type of cancer that forms in the tubes connecting the liver with the gallbladder and small intestine in June 2019 and died a short time later.
The health board said the patient, known only as patient A in the report, had not showed any signs of advanced liver disease.
When an ultrasound scan found there were abnormalities further investigations were carried out, however, a diagnosis could not be established until a liver biopsy was obtained and reviewed by specialists.
The board aknowleged that there had been a delay in the liver biopsy being taken and the results were sent to the wrong consultant.
An expert who took part in the inquiry was critical that the patient had not even been made aware that the tests were checking for cancer. The family said they had been "reassured" that nothing sinister was going on.
The SPSO said: "In light of the evidence we have seen and the advice received, we found that: the care and treatment provided by the board before and leading up to the diagnosis was unreasonable; and the board failed to reasonably communicate with A and they should have told A much earlier that the tests being carried out were for cancer.
"It is possible A’s quantity of life would have been better, and therefore, A could have lived longer if the diagnosis had been made earlier."
"As such, we upheld C’s complaints."
The health board was ordered to apologise to the family and improve the tracking of suspected cancer cases.
Eddie Docherty, executive nurse director at NHS Lanarkshire said: "We regret any instance where we fail to provide the highest standards of care for our patients.
“We have fully accepted the recommendations within the Ombudsman’s reports and will develop an action plan to address them.
"The lessons learned will be shared to help avoid similar occurrences in future.”