Decision Report 201508008

Summary

Mr C was referred to the neurology department at the Southern General Hospital for the investigation of pain that he had suffered since he was involved in a road accident. Mr C attended at the neurology service for an extended period of time without a formal diagnosis of his condition being made. While we were investigating Mr C's concerns about delay in diagnosis and the way his complaint had been handed by the board, he advised us that he had received a diagnosis from a private health provider.

After taking independent advice from a consultant neurologist, we did not uphold Mr C's complaint about the delay in diagnosis. The advice we received was that while Mr C had a long patient journey, this was not unreasonable in the context of his complex case. The adviser considered that if the board had not carried out all the tests they had before Mr C received his private diagnosis, it was likely that these would still have been necessary before a diagnosis could be reached.

We upheld Mr C's complaint about the way the board handled his concerns. We found that there were some instances where the board's complaint responses did not accurately reflect the information in his medical records. This related to a test which they advised was carried out at a consultation. However, the record of the consultation made no reference to this taking place. We made three recommendations in relation to this matter.

Recommendations

We recommended that the board:

• ensure that the appropriate tests are conducted and documented at consultations;
• apologise for the complaints handling failing identified in this investigation; and
• ensure that complaint responses accurately reflect the medical records.