Overview
The complainant (Mrs C) complained against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her husband (Mr A) received from Ayr Hospital (the Hospital), following his collapse on a public transport bus. Mr A subsequently became completely tetraplegic within a short period of time after he arrived at the Hospital.
Specific complaint and conclusion
The complaint which has been investigated is that following Mr A's admission to the Hospital on 15 January 2010 there were unacceptable delays in his diagnosis and treatment (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) ensure that measures are taken to feedback the learning from this event to all Accident and Emergency staff to ensure that similar situations will not recur;
- (ii) conduct a Significant Event Review of this case with an emphasis given to the misinterpretation the radiologist gave to the findings of the scan of 18 January 2010;
- (iii) ensure that all Accident and Emergency staff are familiar with and adhere to Nursing and Midwifery Council Guidelines on record-keeping;
- (iv) ensure that all Accident and Emergency staff are familiar with and adhere to Scottish Intercollegiate Guidelines Network Guidance on suspected head / neck injury;
- (v) review the procedure the Hospital follows should MRI scanning outside normal hours (08:00 to 17:00) and at weekends be urgently required;
- (vi) review the procedure for imaging to include image appraisal and the quality of films;
- (vii) review the provision and availability of collars; and
- (viii) apologise to Mrs C for the failures identified in this report.