Decision Report 201706831

Summary

Mr C complained about the care and treatment provided to him at the Queen Elizabeth University Hospital. Mr C had suffered visual disturbance and had attended the Emergency Department (ED). He was assessed and discharged as there were no abnormal findings. The following day, Mr C attended the ED again as he again was suffering from visual disturbance, and also had some leg numbness. Clinical examination was again normal and he was discharged. Later that day, Mr C attended the ED again with new symptoms of facial muscle weakness. He was admitted for further investigation and was found to have suffered a stroke. Mr C complained that it took three attendances for him to be diagnosed and he felt that if he had been given treatment on his first attendance the visual loss which he subsequently suffered would have been prevented.

We took independent advice from a consultant in emergency medicine and from a consultant stroke physician. We found that, whilst the overall standard of Mr C's care and treatment was reasonable, on his second attendance the possibility of transient ischaemic attack (a ‘mini stroke’ caused by temporary disruption of blood supply to the brain) should have been considered. We, therefore, upheld this aspect of Mr C's complaint.

Mr C also complained that he had not received appropriate follow-up. We found that follow-up was of a reasonable standard and, therefore, did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board failed to respond to his complaint in a timely manner. We found that the board had taken well over 20 working days to respond to his complaint, and had failed to keep him updated about the delays. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to consider the possibility that he had suffered a transient ischaemic attack. 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:

• In similar circumstances, a differential diagnosis of transient ischaemic attack should be considered.

In relation to complaints handling, we recommended:

• Where a complaint response takes more than 20 working days, the board should explain the reasons for the delay and agree a new timeframe.

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.