The man sought medical advice at his local health clinic, suffering from abdominal pain, loss of appetite and coughing blood, according to local paper Värmlands Folkblad (VF).
He was referred to the nearby hospital in Arvika, where he underwent an ultra sound scan and a lung x-ray, and the results caused the doctors to believe he was suffering from a broken rib.
However, no better, the man returned to the clinic in June, new examinations were carried out at the hospital and later at another hospital in the area. This time the patient was prescribed laxatives and painkillers.
According to VF, there was a suspicion of lymphoma, but a referral to have a scan, which was written in June, wasn’t carried out until October.
At the beginning of November, the suffering man underwent a gastroscopy, which detected cancer of the larynx. He died a few weeks after getting his diagnosis.
The incident has been reported twice to the National Board of Health and Welfare (Socialstyrelsen) according to Lex Maria, the informal name for regulations governing the reporting of injuries or incidents in the Swedish health care system.
One of the reports comes form the county council (Landstinget), and the other from an individual.
According to VF, the latter states that the patient had been forced to see at least 31 different doctors and that that none of them took him or his suffering seriously.
In the county council’s independent investigation it was found that there had been no coordination of the patient’s care among the attending doctors. They also found fault with the sharing and filling in of the patient’s medical records.
At the National Board of Health and Welfare they are highly critical of what has happened and call it “remarkable” that twenty physicians can have missed that the origin of the abdominal pain came from the upper part of the digestive system.
If a gastroscopy had been carried out sooner, the patient may have had a diagnosis months earlier and received better treatment the agency concluded, according to VF.
The agency has now asked the county council to present a plan for how to prevent this from happening again and new guidelines for dealing with patients’ abdominal pain latest by May 20th, according to VF.