• Case ref:
    201802126
  • Date:
    November 2018
  • Body:
    Tayside NHS Board
  • Sector(s):
    Health
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Not upheld, no recommendations

Summary

Mr C complained about the treatment he received in A&E at Ninewells Hospital. Mr C had had attended with symptoms of severe headache and double vision. He was given painkillers and told to return for a scan the following week. A few days later Mr C awoke with blood coming from his nose and mouth and contacted the Acute Medical Unit. He was asked to return the following day for a head scan which found that Mr C had suffered an internal carotid artery dissection (a tear in one of the arteries in the neck). Mr C felt that the head scan should have been taken when he first attended hospital.

We took independent advice from a consultant in acute medicine. Our investigation of the complaint was affected as the original case notes could not be located by the board and we had to rely on the contents of the immediate hospital discharge letter and a statement made by a doctor during the board's investigation of the complaint. We were unable to establish if the doctor managed to obtain a full medical history from Mr C about his symptoms and whether a full assessment had been carried out. There was some evidence that a full examination had been performed. There was no question that a head scan was required, and had insufficient resources been an issue at the time, then Mr C should have been recalled, ideally, the following day. However, this was dependent on the reported symptoms at that time. We found that appropriate advice was given to Mr C to seek further medical advice should his symptoms deteriorate. On balance, in view of the missing clinical records, it was felt that we could neither uphold or not uphold the complaint. We made no finding on the complaint.