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Case ref:201909705
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Date:June 2022
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:Clinical treatment / diagnosis
Summary
A was admitted to A&E at the Royal Hospital for Sick Children with symptoms including retching, a purple rash on their leg and feeling agitated. A had a diagnosis of quadriplegic cerebral palsy (form of cerebral palsy in which all four limbs are affected), was non-verbal and received PEG feeding (passing a thin tube through the skin to give food, fluids and medicines directly into the stomach). A was subsequently admitted to hospital after assessment.
A was observed in hospital and underwent a number of investigations. A gastrojejunal tube (when a thin, long tube is threaded into the jejunal portion of the small intestine) was inserted to address concerns about A's nutrition. A became increasingly distressed following the procedure and their condition deteriorated. A underwent emergency surgery where a caecal volvulus (obstruction of the bowel) was diagnosed.
C complained to the board that they had missed several opportunities to diagnose and treat the bowel obstruction which was causing A's symptoms. The board produced a report detailing the history of A's care and decision making during the period. The main finding was that there were no identified failings in the care provided to A and that there was no misdiagnosis of A's condition.
Dissatisfied with the board's response to the complaint, C brought their complaint to our office. We took independent advice from a paediatric gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) and a paediatric radiologist (a specialist in the analysis of images of the body). We found that the investigations and treatment provided were appropriate. There was a delay in obtaining a CT scan, however the delay was relatively small in the context of the period of A's admission. As such, we found that the care and treatment provided to A was reasonable and we did not uphold the complaint.
There were some aspects of care which we identified as being suitable to feedback to the board for reflection and consideration.