Decision Report 201508012

Summary

Miss C complained about the clinical treatment provided to her late brother (Mr A). Mr A was admitted to Ninewells Hospital with chest pain. He was diagnosed with a chest infection and discharged the next day. Mr A died of a heart attack a few weeks later. Miss C was concerned that the hospital did not find a problem with Mr A's heart, particularly as he was admitted with chest pain and had a family history of cardiac (heart) problems.

In response to Miss C's complaint to them, the board said Mr A did not show signs of a heart attack during his admission and that they considered the care provided to have been reasonable. They noted that recovering from a chest infection can put an extra strain on the heart, which may have precipitated a heart attack, but that this could not have been predicted.

After taking independent medical advice, we upheld Miss C's complaint. While we were advised that the care provided was reasonable at first, it was not clearly recorded in the medical records that Mr A was properly reviewed before discharge and that he had no ongoing symptoms of concern.

However, we were not critical of the hospital not identifying a problem with Mr A's heart. The adviser explained that the investigations carried out were reasonable and supported the diagnosis of a chest infection. Based on the information available to the hospital at the time, the adviser considered it was reasonable that the doctors did not investigate a possible cardiac cause for Mr A's pain.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the lack of a detailed assessment on the day of discharge; and
• ensure the consultant reflects on our findings as part of their next annual appraisal.