CASE STUDIES
Incorrect discharge of patient by accident and emergency department Case 201201464 Positive action taken by organisation A 70-year-old man was admitted to a hospital accident and emergency department after losing consciousness at home. A doctor examined him, decided that he had a urinary tract infection and sent him home with antibiotics and painkillers. His family were told that if they were anxious they should bring him straight back. Shortly after returning home, the man became more unwell. His family called an emergency ambulance and he was readmitted. After a scan he was found to have an abdominal aortic aneurysm (a ballooning of part of the large blood vessel in the abdomen), which had ruptured. He died early the next day. The man’s wife complained that staff failed to thoroughly assess and treat her husband, and simply discharged him home. In response to the complaint, among other things, the board said that this type of aneurysm was rare and not easily spotted. Although his wife thought he should have been scanned earlier, they said it was not routine to scan all patients with abdominal pain. The decision on whether to do so would be a matter of clinical judgement, based on the patient’s symptoms and the doctor’s clinical findings. Our investigation found that the man’s symptoms meant that he should have been immediately assessed by a doctor. His medical records did not show a detailed history or examination note, or any obvious attempt to rule out certain, potentially serious, reasons for his condition. Our independent medical adviser said that he should not have been discharged. We noted, however, that the board had learned from the events in this case and had put in place a number of changes so we made no recommendations about the care and treatment provided.
Recommendations The board apologise to the man’s wife for the failures of care and treatment, and for unreasonably discharging her husband from hospital.
Pressure ulcers – failures in nursing care Case 201101660 This complaint was from a man who has been wheelchair-bound for many years, with limited ability to move or to feel any pain or discomfort in the lower half of his body. When he was admitted to hospital, he was dependent on staff for the majority of his daily living needs, including his positioning. After three days in hospital, staff identified that he had a pressure ulcer (pressure sore) which they treated. By the time he was discharged, however, this had developed into a serious ulcer. The man had to endure many months of bed rest and further care before he could be referred to a plastic surgeon to have this repaired. He complained to us that the ulcer developed because he had inadequate care and treatment in the hospital. We found that at first he was correctly noted as being at high risk of this, and was regularly assessed. However, the standard of management later fell below national standards because of a knowledge-skills gap in assessing the condition of the ulcer. We found clear evidence that staff did not identify and grade the seriousness of the wound, or take the most appropriate action.
Recommendations The board ensure their tissue viability training programme provides education and training for the assessment, grading and treatment of pressure ulcers in line with national guidance; and undertake an audit of hospital wards to ensure that pressure ulcer care and management is in line with national guidance.
SPSO ANNUAL COMPLAINTS REPORT 2012 > 2013 HEALTH PAGE 24