Decision Report 201400638

Summary

Mrs C's late mother (Mrs A) had a fall in the care home where she lived. The next morning a carer accompanied her to A&E at Monklands Hospital. A doctor examined Mrs A, but considered that she only had bruising and did not arrange an x-ray. The doctor discharged Mrs A back to the care home.

The next morning, care home staff remained very concerned about Mrs A, and she returned to A&E, accompanied by another carer, who was told to specifically ask that Mrs A be given an x-ray. Mrs C said that A&E staff were very reluctant to x-ray Mrs A and, when the carer asked them to call the care home unit manager to discuss this, they told the manager that Mrs A had already been x-rayed on the previous day. However, after checking the records A&E staff acknowledged that this had not happened. Another doctor examined Mrs A and arranged an x-ray, which showed Mrs A had a fractured collarbone.

Mrs C phoned the hospital to complain about her mother's treatment, but staff told her she had to put her complaint in writing, and that Mrs A had to give written consent to the complaint being made. Mrs C wrote and complained, but the board did not receive this until Mrs C also sent the letter to her MSP, who forwarded it to them (some three weeks later). Mrs C complained about the delay in x-raying Mrs A, the failure to give Mrs A any pain relief on her first visit to A&E and the attitude of the staff member when she phoned to complain. The board apologised for the failure to correctly diagnose Mrs A's fracture on her first visit. The board said that, given Mrs A's age and frailty, she should have been given an x-ray, and the doctor involved had accepted this as a learning point for the future. The Board also apologised for the mistaken assumption staff made during Mrs A's second visit to A&E that she had already been x-rayed, and for the attitude of the staff member when Mrs C phoned to complain.

Mrs C was not satisfied with the board's response, and complained to us about Mrs A’s care and treatment, as well as the handling of her complaint. After taking independent medical advice, we upheld Mrs C's complaints. We found that the doctor on the first visit to A&E should have arranged for an x-ray. However, we noted that the board had already acknowledged and dealt with this. We found no evidence that staff were unreasonably reluctant to x-ray Mrs A when she returned to A&E. We did not criticise staff for not providing pain relief during Mrs A’s first visit to A&E, because we found that they had checked that she had already taken pain relief. However, we found that staff had failed to follow their complaints handling policy by not accepting Mrs C's complaint verbally and by not handling it within the required time-frames.

Recommendations

We recommended that the board:

• remind A&E triage staff at Monklands Hospital of the importance of fully reassessing any patient who returns to A&E, including taking a new set of observations, to ensure that nothing has been missed or overlooked;
• apologise to Mrs C for the failings our investigation found; and
• review their processes for accepting and processing verbal complaints (including obtaining consent, where required, where a complaint is made verbally on behalf of someone else); and tracking expected complaints time-frames (including updating complainants where anticipated time-frames will not be met).