-
Case ref:202002316
-
Date:May 2021
-
Body:Lanarkshire NHS Board
-
Sector:Health
-
Outcome:Upheld, recommendations
-
Subject:Clinical treatment / diagnosis
Summary
C, an advice and support worker, complained to the board on behalf of their client (A) who had attended A&E at University Hospital Wishaw. A had sustained severe pain and swelling behind their right eye and was concerned that they may have suffered a stroke. A was seen by the stroke team who confirmed that A had not suffered a stroke and A was discharged home with a diagnosis of severe migraine. A began to have the same problems with their left eye two weeks later and by that time still had not regained sight in the right eye. A reattended the hospital. After initially being told it was another migraine incident, which they did not accept, A was referred to another hospital and then to ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) for further treatment including eye drops and laser surgery. A has regained sight in the left eye but will not regain sight in the right eye. A had concerns about the lack of treatment provided at their first attendance at A&E.
We took independent advice from a consultant in emergency medicine. We found that the A&E doctor, although reaching a reasonable diagnosis based on some of A's reported symptoms, failed to conduct appropriate investigations on A's specific eye symptoms which had been recorded by a nurse and a paramedic at the time. This should have resulted in a referral to ophthalmology. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to A for the failure to refer them for an ophthalmology review. 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:
- The A&E doctor should be aware of the relevant recorded findings of other health professionals when conducting a medical review of patients.
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.