Decision Report 201400826

Summary

Mrs C complained that the board's decision to discharge her from the A&E department of the Royal Infirmary of Edinburgh was not reasonable.

Mrs C had accidentally swallowed her dental plate and was taken to A&E by ambulance. She complained that her plate caused her to choke and that she waited a long time in A&E before being sent for an x-ray. Although the x-ray did not identify her dental plate Mrs C said she knew it was still in her throat when she was discharged; around two weeks later, she started choking, coughed and dislodged it.

As part of our investigation, we took independent advice from two of our advisers (the first was an experienced ear, nose and throat specialist and the second was an A&E consultant). Our first adviser said the focus of staff in A&E appeared to have been on Mrs C's digestive system, as opposed to her throat (her chest was x-rayed and she was told to return if she developed abdominal pain). He explained that there were additional steps that could reasonably have been taken by A&E staff prior to Mrs C's discharge and our second adviser also said that A&E staff could reasonably have done more.

Our role was to consider whether the care and treatment Mrs C received in A&E was reasonable in the circumstances at the time. This meant we could not rely on hindsight and, as our first adviser pointed to some things that may not have been immediately apparent to a non-specialist, we took his relative expertise and experience into account (in addition to our second adviser's view). Taken as a whole, we were satisfied that the board's decision to discharge Mrs C had been unreasonable in the circumstances and we upheld her complaint. We made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• use this case as a learning point for staff at the next departmental meeting, in particular in relation to carrying out appropriate examinations and recording this in the medical records.