Decision Report 201804111

Summary

Mrs C complained about the treatment which her son (Mr A) received at Hairmyres Hospital. Mr A was admitted with severe stomach pains, vomiting of blood and blood in his stools. The diagnosis was a bleed within his intestinal tract. Initially the plans were that an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside) would be carried out while Mr A was a patient. Mr A was then discharged home after a few days and arrangements were made for him have an endoscopy as an out-patient within four to six weeks. A letter was issued to Mr A asking him to make contact for a date for the endoscopy, but he did not respond. He was then admitted to another hospital as an emergency where he underwent surgery for a perforated gastric ulcer (condition in which an untreated ulcer can burn through the wall of the stomach or other areas of the gastrointestinal tract). Mrs C felt that had Mr A received the endoscopy while an in-patient, it may have prevented the ulcer perforation.

We took independent advice from a surgeon. We found that while Mr A was in hospital the staff carried out appropriate investigations in order to arrive at a diagnosis. There is guidance that Mr A should have received an endoscopy while an in-patient. However, this would have been for the purposes of establishing whether Mr A was continuing to lose blood; but as Mr A showed signs of improvement, this was not the case. It was appropriate to discharge Mr A from hospital as he appeared to be stable, and the revised plan for an out-patient endoscopy was then reasonable in the circumstances. We did not uphold the complaint.

Although we did not uphold the complaint we highlighted issues of concern regarding record-keeping, risk assessment and communication with primary care as feedback to the board in an effort to improve learning.