Decision report 201201885

Summary

Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death.

We took independent advice from one of our medical advisers, who explained that mesenteric ischemia is a very difficult condition to diagnose. It is usually diagnosed by excluding other causes and this can take some time. We were satisfied that the board carried out appropriate assessment and investigations to exclude other causes to diagnose Mrs C's condition. However, we found that the diagnosis of mesenteric ischemia should have been considered sooner in view of the fact that Mrs C was known to have vascular disease.

The board decided that operating on Mrs C would be very high-risk, and referred her to another board for advice. Although we found that this was in itself reasonable, there were delays in obtaining the advice. It was then decided that Mrs C required a major surgical operation, which would carry some significant risks to her health. The surgeon who had been managing Mrs C's care was due to leave the board at that time. He referred Mrs C to another board and asked that they take over her management. Again, given the circumstances, we found that this was reasonable. However, we found that the referral should have been more urgent and the board should have pursued this when no response was received from the other board.

Mrs C's condition deteriorated further before she was seen by the other board. She underwent an emergency surgical procedure and was admitted to intensive care. A second procedure was carried out to review her bowel. It was decided that the surgical options were limited, and the surgeon could not carry out a bowel resection (partial surgical removal). Mrs C subsequently passed away.

Our adviser said that Mrs C was a high-risk candidate for surgery and it was likely that this would have been unsuccessful. It could also have led to other parts of her system being compromised, even if it had been undertaken at an earlier opportunity. It would have been inappropriate to carry out surgery without obtaining advice from the other board. Although we upheld Mr C's complaints, as we found that there had been delays by the board, both before and after Mrs C was diagnosed with mesenteric ischemia, our adviser said that the outcome was unlikely to have been different if these delays had not occurred.

Recommendations

We recommended that the board:

• make the clinical staff involved in Mrs C's treatment aware of our finding on this matter; and
• review the management of Mrs C's case and consider how they can ensure continuity of care when a patient is referred to another board for treatment.