Decision Report 202410955

Summary

C complained about the standard of medical care provided by the board during two attendances at A&E with severe abdominal issues. C was discharged home on both occasions, and shortly after the second discharge, the results of a magnetic resonance scan (MRI) indicated that they had significant abnormalities of the bowel. C was then admitted to hospital for treatment of inflammatory bowel disease.

We took independent advice from consultants in emergency medicine and general medicine. We found that the standard of medical care provided was not reasonable in that recordkeeping and communication was poor, C was misdiagnosed with constipation at the second visit, there was a failure to act on the results of the MRI scan and discuss C’s care with the relevant specialists at the second visit, and there was a delay in treating C and admitting them to hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Patients’ records should be completed to a reasonable standard and in line with the relevant professional standards. Patients with abnormal test results should be acted on fully and within a reasonable time. Patients with a complex medical history and repeated presentation should have a full differential diagnosis list and all relevant specialists should be consulted with.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.