Summary
Mr C complained on behalf of his sister (Miss A) who had amongst other things profound learning difficulties, type 2 diabetes and was blind. He said that after falling out of bed and hurting her neck on 12 December 2015, she attended the Emergency Department (ED) of Glasgow Royal infirmary. Although the board maintained that Miss A had been treated reasonably, Mr C said that staff did not take into account her serious disabilities when examining and treating her and she was discharged home. Miss A's condition deteriorated and she returned to the ED where she was later given an x-ray and CT scan which showed fractures in her neck. She was admitted to the National Spinal Injuries Unit.
We took independent advice from a consultant in emergency medicine and from a registered nurse. We found that despite the fact that Miss A had serious and profound learning difficulties which were detailed in documentation that accompanied her to the ED, these were not properly taken into account, a senior opinion was not obtained nor were available objective assessment tools used. Mr C's opinions were not sought to establish whether he could input into the findings of her examination. We upheld the complaints.
Redress and recommendations
The Ombudsman recommends that the Board:
- make a formal apology to Mr C and Miss A for the shortcomings identified;
- staff involved in Miss A's care on the day concerned should be made aware of the content of this report to allow them the opportunity to reflect and also consider it at their next formal appraisal;
- apologise to Miss A (copied to Mr C) that when communicating with her, staff failed to take her learning difficulties into account;
- apologise to Mr C for not reverting to him for his assistance in this matter; and
- review their advice to staff members about treating people with disabilities to establish whether or not it is currently fit for purpose. If it is not, they should provide updated advice and guidance.