Decision report 201103311

Summary

Mr C had ulcerative colitis (a type of inflammatory bowel disease) and attended a specialist appointment at Hospital 1. He was told that he would be reviewed at a follow-up appointment in three weeks. Mr C's wife (Mrs C) complained that no follow-up appointment was arranged. Mr C's condition deteriorated and he was referred to the accident and emergency department of another hospital (Hospital 2). He was admitted and treated with intravenous drugs (drugs administered into a vein). The drugs had no effect and Mr C was identified as needing an operation. Mrs C said she was told that her husband would require two further operations after that, and that this might have been avoided had he been treated sooner.

Mrs C complained that the board did not provide Mr C with reasonable care and treatment before his surgery. She also complained that they did not take reasonable action to address a known issue with follow-up appointments and that they delayed in responding to her complaints correspondence.

We upheld all Mrs C's complaints. Our investigation found that although an initial follow-up appointment was made, later planned appointments were not confirmed with Mr C. In relation to the complaint about Mr C's treatment, our medical adviser considered that the initial prescribing of steroids was appropriate. However, as Mr C's condition worsened, he should have been admitted for a course of intravenous drugs. Delays to the follow-up appointment meant that by the time treatment was provided by Hospital 2, it was too late for it to be effective. Taking all the evidence, and the advice of our medical adviser, into account we concluded that Mr C would have required the three operations at some point. However, the delay to the follow-up appointment meant that all the surgery was required sooner than it would have otherwise been, resulting in limited time for Mr C to prepare for the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for the issues highlighted in our investigation;
• provide us with details of the service manager for medicine's review findings and any action proposed as a result of the review; and
• take steps to ensure that all patient referrals and follow-ups are acted upon in accordance with the relevant standards.