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Case ref:201803284
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Date:November 2019
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Body:Highland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about the care and treatment his relation (Ms A) received at Raigmore Hospital. Ms A suffered from MPO ANCA associated vasculitis (a rare autoimmune disease) and was admitted to hospital with symptoms of diarrhoea and vomiting, headaches and abdominal pain. Ms A experienced episodes of haemoptysis (coughing up blood) while in hospital and died later that day.
We took independent advice from an adviser in acute medicine. We found that, when Ms A was admitted to hospital, a consultant review indicated that a pulmonary haemorrhage (an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the alveoli) was a potential concern along with two other possibilities. We considered it was reasonable at the outset that the board did not proceed to give Ms A a chest x-ray as gastroenteritis (inflammation of the stomach and intestines) was suspected and there was only one episode of haemoptysis. However, we found that there was an unreasonable delay in performing a chest x-ray on Ms A following a second episode of haemoptysis. There was, therefore, a delay in identifying a pulmonary haemorrhage. We noted a member of the nursing staff appeared to identify the possibility of a pulmonary haemorrhage, and whilst this was communicated to the doctor, it was not acted upon. We upheld Mr C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for an unreasonable delay in performing a chest x-ray on your Ms A following a second episode of haemoptysis and a delay in identifying a pulmonary haemorrhage, given a consultant review indicated a pulmonary haemorrhage was a potential concern. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
What we said should change to put things right in future:
- Raise awareness and understanding of MPO ANCA associated vasculitis and pulmonary haemorrhage. Ensure all staff feel they can raise concerns with a senior member of staff if they consider their concerns are not being addressed. Ensure safety measures are in place to ensure less experienced staff are aware of potential symptoms/problems.