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Case ref:201908098
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Date:May 2021
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained that the board failed to appropriately triage their relative (A) when A self-presented to the Medical Assessment Unit (MAU) at Western General Hospital feeling unwell. A spoke with the receptionist who took details of their symptoms and, having discussed A's symptoms with clinical staff, the receptionist advised A that they should contact NHS 24.
A left the hospital and contacted NHS 24 who advised A to take paracetamol for the pain. A was taken to another hospital in the early hours of the next day and had an emergency operation for a ruptured appendix.
In response to the complaint, the board explained that the receptionist acted in line with their normal processes. C was not satisfied with the response provided and brought the complaint to our office.
We found that the board were unable to evidence that A was reviewed by a triage nurse or doctor in person as per their protocol. Given there was no evidence that the appropriate protocol was followed, we upheld the complaint. In addition, having reviewed the handling of C's original complaint, we concluded that the board failed to appropriately investigate and respond to C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to A for failing to follow the protocol when they attended the hospital and for failing to take appropriate records of the assessment and triage. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
- Apologise to C for failing to appropriately investigate and respond to their complaint. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
In relation to complaints handling, we recommended:
- Relevant staff should be aware of the requirements of the complaints handling procedures, particularly regarding collating and assessing relevant evidence in determining a complaint.
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.