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Selected Investigations Completed April - September 1998 > Part I, Case no. E.1313/96-97
Matters considered: Lack of priority given to correcting anti-coagulant state; diagnosis and treatment of internal bleeding
Complaint against: Southampton University Hospitals NHS Trust
Summary of case
Mr X, who was taking anti-coagulants for his heart condition, fell and dislocated his elbow in June 1996. He was taken to the accident and emergency (A and E) department of Southampton General Hospital by ambulance. Mr X's wife gave the ambulance crew his anti-coagulation therapy record book. On arrival at the hospital, she warned staff of the danger of her husband bleeding profusely because of the effect of the anti-coagulants. Over the next three weeks Mr X had a series of operations on his arm to relieve the pressure caused by internal bleeding, and was left with impaired use of his hand.
Findings
The doctor who treated Mr X's elbow injury in the A and E department, and the doctor who admitted him to a ward, were aware that he was taking anti-coagulants. None of the medical staff involved tested Mr X's anti-coagulant status on that first day; the Ombudsman upheld the complaint that insufficient priority was given to correcting his anti-coagulant state. The Ombudsman did not uphold the complaint that the subsequent diagnosis and treatment of internal bleeding was inadequate. The Ombudsman's independent professional assessors for this complaint remarked that the clinical record-keeping was inadequate; the Ombudsman agreed with that view.
Remedy
The Trust agreed to test the anti-coagulation status of all trauma patients on anti-coagulants who were treated in the A and E department, and to take steps to improve clinical record keeping in the A and E department. They also agreed to apologise to Mr X for the shortcomings which the Ombudsman identified.
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