Decision report 201105481

Summary

Mrs C said that her husband (Mr C) was involved in an accident in which he fell from height, and was airlifted to hospital. She said that following various CT scans (special scans that use a computer to produce an image of the inside of the body), Mr C was diagnosed with a spinal fracture. He was transferred to another hospital nearer to where they lived, but suffered a major stroke that resulted in him having severe communication difficulties. After Mr C had the stroke, it was diagnosed that Mr C's carotid artery was dissected (the layers of the artery wall supplying oxygen-bearing blood to the head and brain became separated). Mrs C complained that the hospital did not provide clarity about the treatment Mr C had received from them and that her complaint about this was not adequately addressed.

Two of our independent medical advisers considered all aspects of this case. We took account of their advice along with all the documentation provided by Mrs C and the board. We did not uphold Mrs C's complaints about treatment and complaints handling. The advisers said that Mr C had been correctly assessed and investigated at the hospital, in accordance with standard UK practice, and that appropriate diagnostic imaging techniques were used. They also said that clinicians diagnosed Mr C correctly and he had received a reasonable level of care. Our investigation found that the board had appropriately investigated and responded to Mrs C's complaint. However, we considered that they had failed to respond as agreed to Mrs C's enquiry about the board's protocol for image scanning, and we upheld that aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the learning from this complaint to all staff to ensure such an evolving communication failure will not recur; and
• apologise to Mrs C for this failure and the upset it has caused.