Decision Report 201302488

Summary

Mr C's wife (Mrs C) was referred to Wishaw General Hospital by her GP. She had been experiencing severe abdominal (stomach) pain and back pain. She was known to have an abdominal aortic aneurysm (a weak point in the blood vessels, causing them to bulge or balloon out) but when her GP examined her he felt another mass in her abdomen. Mrs C saw a consultant surgeon, who could not feel the mass and, after checking a recent scan, discharged Mrs C with pain medication. Mrs C continued to experience severe pain. Nine days later she was readmitted to the hospital as an emergency, and was found to have a bowel perforation (a hole in the bowel). As she was not fit for surgery, palliative care (care provided solely to prevent or relieve suffering) was put in place, and Mrs C died five days after being admitted. Mr C complained that, had the surgeon conducted a more thorough examination, the severity of his wife's condition might have been identified and she might have been treated.

We took independent advice on this case from one of our medical advisers, who is a consultant colorectal (bowel) surgeon. We found that the records taken by the surgeon who examined Mrs C were sparse and of poor quality. The surgeon had provided us with a separate written statement detailing the examination and findings, which our adviser found reasonable in the circumstances. However, the lack of contemporaneous notes cast doubt as to how much consideration the surgeon gave to Mrs C's underlying ongoing symptoms. Although we considered it reasonable for Mrs C to be discharged home after the initial examination, we were critical of the board for not arranging urgent follow-up tests to establish the source of her symptoms.

Recommendations

We recommended that the board:

• apologise to Mr C for the issues highlighted in our decision letter;
• discuss Mrs C's case with the consultant surgeon at their next appraisal; and
• remind the consultant surgeon and her team of the importance of maintaining detailed medical records.