Decision Report 201701009

Summary

Ms C complained to us on behalf of her sister (Ms A). Ms A had sustained a head injury after a climbing accident. She attended hospital and was kept in overnight. After being discharged, Ms A became unwell, was visited at home by an out-of-hours GP and was then taken by ambulance to the emergency department at another hospital, St John's Hospital. She was diagnosed with post-concussion syndrome (when concussion symptoms last for weeks or even months after the injury which caused the concussion) and was discharged home. Ms A still felt unwell and was subsequently admitted to a third hospital and where she was diagnosed as having had a series of mini-strokes. Ms C complained that the board failed to provide Ms A with appropriate care and treatment when she attended St John's Hospital and unreasonably discharged Ms A from St John's hospital.

We took independent advice from a consultant in emergency medicine, a general medicine consultant with experience in stroke medicine and a radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans). We found that there were two documented symptoms that should have prompted the emergency staff to consider a diagnosis of stroke for Ms A. We also found failings in the board’s handling of the radiology aspects of Ms C’s complaint and her concerns about the out-of-hours GP’s notes on their assessment of Ms A. We upheld this aspect of Ms C's complaint.

In terms of Ms A’s discharge, we found that Ms A was not well enough to have been sent home and should not have been discharged from hospital. We considered that her working diagnosis should have been stroke, not post-concussion syndrome, and she should have been referred to the hospital’s stroke team. We, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the failings in Ms A’s care and treatment, her discharge from hospital and the investigation of Ms C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Emergency department staff should note key symptoms and reach an appropriate diagnosis, in a case such as this.
• Patients should not be discharged in circumstances such as this.

In relation to complaints handling, we recommended:

• Issues set out by patients in their complaints should be raised with relevant staff in a timeous manner.
• Complaints should be fully and appropriately investigated.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.