Decision Report 201303684

Summary

Mr C's son (Mr A) had a history of symptoms of weakness, numbness and pins and needles, and had previously been seen by neurology consultants. When he had an episode of tiredness, slurring of speech and right-sided weakness, Mr A called an ambulance and was taken to A&E at the Victoria Infirmary. He was examined but was discharged as he had a history of similar symptoms, which had already been investigated, and his condition had improved since he called the ambulance. The next day, Mr A went to his GP, who thought that he might have had a transient ischaemic attack (TIA - a 'mini-stroke'). The GP referred him urgently to a TIA clinic, and he was offered an appointment for eight days later. A couple of days after visiting the GP, however, Mr A was in some distress and Mr C took him to A&E at another hospital, where he was admitted and diagnosed with a stroke. Mr C complained that A&E doctors at the Victoria Infirmary had not treated his son properly when he went there with stroke symptoms.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaint. Our adviser said that the doctor was brief in his approach, and placed too much emphasis on Mr A's history of intermittent symptoms, which distracted from the fact that he had features of a TIA. We were critical of the A&E doctor's failure to take a detailed and accurate history from Mr A, and to make use of the history recorded by the ambulance staff and A&E nurse, which would have pointed to a TIA.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and Mr A for the failings our investigation identified; and
• ensure that the findings of this investigation are raised with the doctor concerned for reflection.