Decision Report 201906227

Summary

C complained on behalf of their spouse (A) about the treatment A received in hospital after they fell at home and injured their back. A had previously suffered a stroke and, as a result, a computerised tomography (CT) scan of their brain was carried out. This showed no change from the previous CT scan that was carried out. Following an assessment in A&E, it was concluded that A’s back pain was muscular and that they were also suffering from an infection. A remained in hospital for treatment and observation. Twelve days after being admitted to hospital, MRI scans of A’s brain and lumbar spine were arranged. These scans showed that A had suffered a new stroke and had spinal compression fractures. C felt that A should have had an MRI scan when they were admitted to hospital or soon after. In C’s view, this would have confirmed the issues earlier and resulted in more appropriate care being delivered.

We took independent advice from an appropriately qualified adviser. In respect of whether the board unreasonably delayed in diagnosing and treating A’s stroke, we found that there was not sufficient evidence of a fresh stroke to justify an MRI scan at the time of admission. Based on A’s presentation at the time and the need to prioritise their treatment, there was not an unreasonable delay in the board diagnosing and treating A’s fresh stroke. As such, we did not uphold this complaint.

In respect of whether the board unreasonably delayed in diagnosing and treating A’s spinal compression fractures, we found that, given A’s symptoms, an earlier MRI scan of the spine was not indicated. However, we highlighted one clinician’s entry in the medical records that indicated a need for further investigation of A’s back injury that was identified on the date of admission. This entry also suggested that an x-ray was to be arranged. However, this specific entry in the medical records did not appear to have been followed up or acted on, with no narrative in the records to explain why. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for unreasonably delaying in carrying out further investigation into A’s back injury despite a clinician recording this as being indicated. 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 board should review the circumstances surrounding this with the aim of establishing why the clinician’s findings do not appear to have been followed up and why an x-ray was not carried out when the medical records suggest that it was to be.
• The possibility of osteoporotic fractures should be considered in all older patients presenting with new-onset back pain (particularly where trauma could be involved), unless a clear alternative diagnosis is evident. Under these circumstances, imaging should be undertaken to investigate the possibility further.

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.