Decision Report 201401330

Summary

Mrs C complained on behalf of her client (Mrs B) whose late partner (Mr A) was treated in Dr Gray's Hospital and the Fleming Hospital. Mr A was admitted to Dr Gray's hospital after wandering from his home in a confused state. He was subsequently transferred to the Fleming hospital where he reported severe abdominal pain to Mrs B. Although Mrs B reported this to nursing staff, she conceded that she did not think they had heard her. Mrs C complained that Mr A's pain was not investigated by staff until the following day. She also complained that there was a delay in treating Mr A.

Mr A had previously been diagnosed with a duodenal ulcer (an ulcer in the first part of the small intestine). A doctor at the Fleming hospital considered that this may have perforated and arranged for Mr A to be transferred back to Dr Gray's hospital. A chest x-ray was carried out to check for free air in the abdomen which would indicate a perforated ulcer. No free air was identified and Mr A was diagnosed as having a chest infection. His condition was too severe for any invasive treatment so he was treated with antibiotics and fluids until his death the following morning.

We found no evidence of abdominal pain on the day that Mrs B raised this with the nursing staff. Whilst there was no record of her report to the staff, there was evidence of regular reviews of Mr A and his condition was reasonably stable. Once his abdominal pain was identified the following day, along with a marked deterioration of his condition, we were satisfied that staff took appropriate and timely action. We took independent advice from one of our medical advisers, who told us that the chest x-ray did show free air in Mr A's abdomen, however, we found that his treatment was not affected by this oversight, so we did not uphold the complaint.