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Selected Investigations Completed April - September 1998 > Part I, Case no. E.1705/96-97
Matters considered: Cancellation of a diagnostic investigation; sanctioning of discharge without adequate assessment of circumstances and medical problems; inadequate management of fluid balance; insufficient attention paid by nurses to the deterioration of patient's condition on day of discharge
Complaint against: Surrey & Sussex Healthcare NHS Trust (formerly East Surrey Healthcare NHS Trust), Redhill, Surrey
Summary of case
Mrs Q was admitted to East Surrey Hospital on 12 June 1996 with suspected internal bleeding. That afternoon she was examined by a staff grade registrar who queried whether she had either a very large liver or cancer, and suggested an abdominal ultrasound. The ultrasound was not booked and the following day a surgical registrar decided not to pursue it. During her stay in hospital, Mrs Q's husband was concerned that nurses did not monitor her fluid intake adequately. Mrs Q was discharged two days after admission with a tentative diagnosis of constipation. She was re-admitted on 20 June following a home visit by a consultant geriatrician. She was diagnosed as suffering from cancer of the liver and died in hospital on 28 June.
Findings
The surgical registrar believed it was not worth putting elderly patients through tests when there was nothing that could be done for them. The consultant surgeon responsible for Mrs Q's care said that the ultrasound should have been carried out; and that view was supported by the Ombudsman's independent professional assessors. As the ultrasound was only suggested, and not ordered, the Ombudsman could not uphold the complaint as put. However, he considered that, in not carrying out the scan, the Trust had effectively denied Mrs Q the opportunity of knowing the cause of her illness and so had failed in their duty of care. The Ombudsman upheld that aspect of the complaint. The Ombudsman did not uphold the complaints that the surgical registrar had sanctioned Mrs Q's discharge without adequate assessment, or that there was a failure in the nursing care.
Remedy
The Trust apologised for the short-comings identified in the Ombudsman's report.
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