Decision Report 201301524

Summary

Mr C's wife (Mrs C) had hip replacement surgery. She recovered well, but suffered constipation afterwards because of the painkilling medication she was prescribed. After having had no significant bowel movements for more than a week, Mrs C began vomiting and had a painful, hard stomach. Mr C phoned NHS 24 and asked for a home visit from a GP. Mrs C's case was prioritised as serious and urgent and Mr C was told that a district nurse would come within two hours. When the nurse did not arrive, Mr C called NHS 24 again. They investigated and learned that the district nurse would not visit new patients with constipation. Instead it had been arranged for a GP to call Mrs C for a further phone assessment.

Mr C was not happy with this, and was then told that NHS 24 would request an out-of-hours GP to visit within two hours. The out-of-hours GP was, however, required for another more serious call, and arrived about six hours after Mr C's initial call to NHS 24. He gave Mrs C two enemas and a prescription for laxatives. Mr C was advised to monitor his wife overnight and contact her own GP in the morning if she did not improve. As Mrs C did not improve, her own GP visited and immediately referred her to hospital, where she was diagnosed with a perforated bowel that needed emergency surgery. Mr C complained that NHS 24 did not prioritise Mrs C's case appropriately and that she could have been admitted to hospital more quickly had the out-of-hours GP attended sooner.

After taking independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaint. We found that Mrs C's case was treated seriously and given the highest priority, but that NHS 24 should have requested a GP visit rather than a district nurse visit at the start. We were critical of NHS 24 for not gathering relevant information about Mrs C's bowel habits and pre-existing kidney failure, which would have helped staff decide the action to take.

We concluded that, although there was a clear delay in the out-of-hours GP attending, this was partly due to communication problems between NHS 24 and the local health board. NHS 24 and the board had already identified this and had taken action to improve communication. We were satisfied that, although his attendance was delayed, the out-of-hours GP's conclusions and treatment would not have been different had he visited Mrs C earlier. However, we recognised that she would have received the enemas and laxatives sooner and that this might have improved her chances of avoiding a perforated bowel, if it had not already occurred by then. We also recognised that the delays added to the discomfort and anxiety that Mrs C was experiencing.

Recommendations

We recommended that NHS 24:

• apologise to Mr and Mrs C for the issues highlighted in our investigation;
• remind their clinical staff of the importance of establishing each patient's level of renal failure and of taking this into account when progressing their treatment; and
• consider briefing their clinical staff on the need to consider whether patients have passed stools or gas in cases of severe constipation.