Summary
Mr A was admitted to A&E at the Royal Infirmary of Edinburgh after being found at the bottom of a flight of stairs with a suspected head injury. He was assessed as having a reduced level of consciousness but this was attributed to intoxication. It was therefore decided that he would be observed in A&E overnight to ensure his symptoms improved.
Mr A was discharged the following morning and collected by his mother, who found him to be confused and disorientated. However, after discussion with reception staff, she was assured that he was medically fit to leave. On their return home, Mr A's mother remained concerned about his condition, so they attended A&E at Wishaw General Hospital, where a CT scan was carried out. This indicated that Mr A had suffered a brain haemorrhage. He was then transferred to the Southern General Hospital for emergency surgery.
Mr A's sister (Mrs C) complained that Mr A had failed to receive appropriate treatment for his head injury at the Royal Infirmary of Edinburgh. Mrs C felt that Mr A should not have been discharged, given his condition. The board apologised for failing to provide a correct diagnosis and accepted that they had wrongly attributed signs of disorientation and incoherence to intoxication rather than a developing bleed on the brain. The board stressed that assessing patients who have head injuries but are also intoxicated can be very difficult.
During the investigation, my complaints reviewer took independent medical advice on Mr A's treatment from consultants in both emergency medicine and neurosurgery. The advice received was that, under Scottish Intercollegiate Guidelines Network (SIGN) guidance, Mr A should have received a CT scan on admission to the Royal Infirmary of Edinburgh based on his recorded symptoms and that it was not reasonable to attribute those symptoms to intoxication in the circumstances.
My investigation also highlighted a poor level of record-keeping for Mr A's admission. According to records, Mr A appeared to have undergone significantly fewer neurological observations than were required by the board's internal procedure for managing patients with head injuries. We also found that this procedure was not in line with SIGN guidance and that there was no record made of any assessment prior to Mr A's discharge.
Redress and recommendations
The Ombudsman recommends that the board:
- apologise to Mr A and Mrs C for the failings identified in this report;
- review their procedure for the management of patients with a head injury to bring it in line with SIGN guidance;
- carry out an audit of a sample of recent cases of this kind, to ensure they are being dealt with appropriately; and
- carry out a root cause analysis to identify why the medical and nursing staff on duty did not follow the systems in place.