Decision report 201104937

Summary

Mr C complained on behalf of Mr A about the care and treatment he received at a hospital. Mr A had attended the hospital's accident and emergency department (A&E), complaining of dehydration, frequent urination, vomiting and lack of energy. Mr A had also said that his eyesight was blurry and he had a dry mouth. After tests, Mr A was diagnosed with a virus and a low salt count, and discharged. Two days later, Mr A became ill during a journey and was taken to hospital where he was immediately diagnosed as having type 1 diabetes. He was in hospital for about a week. Mr C complained that Mr A was not properly diagnosed during his initial hospital visit.

Our investigation took account of all the available information, including the complaints correspondence and Mr A's medical records. We also obtained independent medical advice. We found that not all the tests that should have been carried out were carried out. This meant that Mr A's condition was not properly diagnosed and he was discharged from A&E too early. Our investigations also showed that the board had not addressed all the complaints Mr C put to them on behalf of Mr A.

Recommendations

We recommended that the board:

• apologise to Mr A for their failure to carry out appropriate diagnostic testing;
• apologise for failing to correctly diagnose Mr A and for discharging him prematurely;
• confirm that the GP specialist trainee raised this case as a significant event at her appraisal;
• confirm to the Ombudsman that they are satisfied that the systems failure that allowed a patient to be discharged from A&E before test results were reviewed has been remedied;
• apologise to Mr C and Mr A for failing to admit when responding to the complaint that there had been faults with regard to Mr A's care and treatment; and
• apologise for their failure to respond to the complaint about the way in which Mr A was spoken to.