Decision report 201201406

Summary

Mr C complained that the board provided inadequate treatment to his adult daughter (Miss A) in a hospital accident and emergency department (A&E) after a fall. Miss A had been taken there after a neighbour found her with a head injury. The doctor who saw Miss A recorded that she was intoxicated with alcohol and had abdominal and chest pain. She noted that Miss A had drunk a bottle of wine, and was difficult to assess and quite uncooperative with questioning. Miss A was initially unwilling to say how she had hurt herself, but eventually said she had fallen in her flat and had gone to the foyer to get help. However, the doctor was not convinced by this.

The doctor noted that Miss A said that the abdominal/chest pain started before she fell and was due to an existing kidney disorder. Miss A refused to have the head injury stitched, so it was cleaned and glued. The doctor arranged for a chest x-ray and routine blood tests. She gave Miss A painkillers and re-examined her after two hours, by which time, the chest and abdominal pain had improved. The doctor recorded that she thought that Miss A had likely suffered a muscular chest injury, and discharged her. Miss A was advised to see her GP in two days to get her bloods rechecked, and to return to hospital if there were any problems. Miss A declined to contact her parents for help to get home.

Miss A returned to A&E later that day, and this time told staff that she had in fact fallen off a balcony. She was admitted and was in hospital for three weeks. A CT scan (a special scan using a computer to produce an image of the body) and x-rays showed that she had suffered a number of injuries.

We obtained independent medical advice on the complaint, and found that, in general, the care provided to Miss A was reasonable. The doctor assessed Miss A in the context of the description she gave of a minor fall, and Miss A had to take responsibility for not saying what had actually happened. If the examining doctor had been aware of how the injury happened, Miss A would have been immobilised and a CT scan would have been requested, which would have shown the extent of her injuries much earlier.

However, our adviser also said that there were a few lapses in the standard of care. There was inadequate questioning about the significance of the head injury, particularly in the context of there being a four centimetre laceration to the head. If the doctor had asked about loss of consciousness, persistent headache, vomiting or amnesia memory loss, then responses might have indicated a need for a CT scan. The adviser also said that it was unlikely that a more senior doctor would have discharged Miss A, and there were a few subtle clues missed. These included a mildly raised respiratory rate, the chest and abdominal pain and a raised white cell count.

Although we upheld the complaint this was a decision taken on balance, in view of the fact that the overall care provided to Miss A was reasonable and the doctor was clearly not assisted by the fact that she was given inaccurate information about how Miss A sustained her injury.

Recommendations

We recommended that the board:

• issue an apology to Miss A for the failings identified; and
• make the doctor aware of our findings.