Decision Report 201402559

Summary

Mr C complained about his treatment when he attended a stroke clinic. He was unhappy that he was sent home the same day, having been assessed and a stroke diagnosis made. He said he lived alone in a third floor flat and the board did not ask how he would get home or check that there was someone there to look after him. He also complained that no follow-up was arranged, particularly in relation to the psychological impact of the stroke, noting that he previously suffered from mental health difficulties.

The board responded indicating that they carried out appropriate investigations to arrive at the diagnosis and sent a results letter to Mr C's GP with a care plan. They noted that Mr C was independent both before and after the stroke and that he had made his own way to the stroke clinic. They assumed, therefore, that he was able to make his own way home. They assured Mr C that a referral would have been made to the appropriate services had the clinical team believed there to be any ongoing physical or psychological problems arising from his stroke.

We took independent advice from one of our medical advisers, who said there was no evidence to suggest that Mr C required admission following his attendance at the stroke clinic. Our adviser considered that the assessment carried out was reasonable in terms of how thorough it was, noting that appropriate recommendations were made to Mr C's GP regarding his future treatment and monitoring. However, our adviser did not agree with the board's position that there were no ongoing psychological difficulties, stating that there was clear evidence of Mr C's previous and current mental health problems at the time of his attendance at the clinic. Our adviser, therefore, considered that Mr C should have been referred to psychology services by the clinic doctor and considered that the care he received in this regard was unreasonable. We also identified a later breakdown in communication which resulted in the neuropsychology department appearing not to have made an onward referral to the mental health team. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings that this investigation has identified;
• arrange for Mr C to be seen again in the stroke clinic for review of his symptoms; and
• highlight to relevant staff the importance of referring stroke patients to psychology services, where appropriate.