Decision Report 201500264

Summary

Mr C complained on behalf of his brother (Mr A) that the board failed to diagnose Mr A's testicular torsion (the twisting of a testicle, which shuts off the blood supply and can result in the loss of the testicle) and inappropriately discharged him from the Southern General Hospital. Mr A later had to have a testicle surgically removed. Mr C was also unhappy with the board's handling of his complaint.

We found that, as acknowledged by the board, there was a series of failings when Mr A was in hospital. The main issue was that an on-call urologist (a doctor who treats conditions of the urinary tract) should have examined Mr A in person to exclude or confirm testicular torsion. We also found that hospital staff who were asked to comment on Mr C's complaint agreed that Mr A should not have been discharged without being examined by the urologist and being given an ultrasound scan (a scan that uses sound waves to create images of structures inside the body). A lack of available beds may have been a factor in Mr A's discharge.

We found that the board's investigation of Mr C's complaint was reasonably thorough, and their letter to him acknowledged failings and apologised for them. However, we found that the investigation was missing a statement from the doctor who took the decision to discharge Mr A. This was an important aspect of the events in question because it was this doctor who raised the issue about there being no available beds. In our view, the lack of evidence from this doctor compromised the board's investigation. We upheld all of Mr C's complaints.

Recommendations

We recommended that the board:

• share widely within the urology service the circumstances of Mr A's care;
• discuss the details of this case with the on-call urologist;
• share the circumstances of Mr A's care with the out-of-hours service and the emergency department;
• explain to us why a statement was not obtained from the doctor who discharged Mr A;
• ensure that the details of this case are discussed with the doctor who discharged Mr A; and
• provide us with confirmation regarding the availability of beds in relation to Mr A's discharge.