Decision Report 201905392

  • Case ref:
    201905392
  • Date:
    September 2020
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

C was admitted to University Hospital Monklands with abdominal pain, vomiting and an inability to pass urine. C was diagnosed with possible appendicitis (inflammation of the appendix) and was operated on the next day. C was discharged after surgery but was later readmitted and underwent further surgery. C complained they should have had their first operation sooner, given the pain they were in.

We took independent advice from a consultant in general and colorectal surgery (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C's first operation was carried out within an acceptable timeframe. We did not uphold this aspect of the complaint.

C complained their first operation was not carried out in a reasonable manner, as they experienced problems afterwards. C had suffered a recognised complication of the operation and we did not find failings in how C's first operation was carried out. We did not uphold this aspect of the complaint.

C also complained that they should not have been discharged home after their first operation, as they were still unwell. We found it was unreasonable that C was discharged home, as they had a raised temperature and inflammatory marker. We upheld this aspect of the complaint.

When C was readmitted to hospital for a further operation, C said that there was an unreasonable delay in carrying it out. We found there was an unreasonable delay giving C a scan, which caused a delay in carrying out their second operation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C for the unreasonable discharge and the delay in carrying out the CT scan. 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:

  • A CT scan should be carried out to aid diagnosis in patients with similar symptoms.
  • Continuing post-operative symptoms of infection should be investigated before discharge in patients at higher risk of infective complications.

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.

Updated: September 23, 2020