Decision Report 201902736

Summary

C was admitted to hospital for an elective hernia repair. The procedure was said to have gone well and it was agreed that C could be discharged home. Before leaving hospital, C took a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential). In C's case, it was thought they had experienced a reaction to the medications they had been prescribed and it was deemed that they could be discharged from hospital. Once at home, C was reviewed by their GP, who arranged for them to return to hospital for further tests. Those tests confirmed that C had had a stroke prior to being discharged from hospital.

We took independent advice from an appropriately qualified clinical adviser. We found that the board failed to document the assessment of C that was undertaken prior to them being allowed to return home. Without that evidence, we were unable to determine whether the assessment of C's symptoms was of a reasonable quality. We reached the view that the board unreasonably failed to diagnose that C had suffered a stroke and upheld the complaint.

In addition, we found that the board's response to C's complaint was too brief, and lacked sufficient detail. There was little recognition that a significant diagnostic error had occurred, or the effect this may have had on C. The board's investigation and response did not note or disclose to C that there was no documentation in relation to this aspect of their care. The response also lacked appropriate detail in relation to the relevant discussions held as a result of C raising their complaint. We made recommendations to the board concerning these points.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose that they had suffered a stroke prior to being discharged home; assess them in sufficient detail; and record details of the assessment in their notes, and discharge letter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should write to C clarifying what action was taken once the educational supervisor was informed of the matter. The response should also provide further feedback in relation to the discussion held at the general surgery meeting, and what actions may have been agreed.

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.