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Selected Investigations Completed April - September 1999 > Part I, Case no. E.374/98-99
Complaint against: Salford Royal Hospitals NHS Trust
Summary of case
On 30 May 1997, Mrs Q found her brother, Mr N, a man with Down's Syndrome, unconscious and with a high temperature. He was taken to the (A&E) department of Hope Hospital where he was examined by an A&E registrar. The registrar considered several diagnoses, including meningitis, but did not record these diagnoses in Mr N's notes. The registrar ordered blood tests, a CT scan and gave Mr N intravenous antibiotics. He discussed his findings and proposed management of Mr N with the A&E consultant but neither doctor recorded their discussion. The CT scan was clear and the registrar referred Mr N to a resident medical officer(RMO). The registrar expected that Mr N would be seen as a matter of urgency and that he would be admitted, but did not record any clinical information at the time of the referral. The RMO did not examine Mr N before finishing her shift in A&E at 5pm. Mr N was later seen by a house officer who referred him to the RMO who had come on duty in A&E at 6pm. This RMO examined Mr N; concluded that he had a urinary tract infection; prescribed antibiotics and told Mr N's family that he could be discharged. The next day Mrs Q took Mr N to Oldham Hospital where he was diagnosed with meningitis. He died a week later. Mrs Q complained to the Trust about the care her brother received on 30 May and an independent review was held of her complaints. The panel's report was critical of failures in communication, but concluded that Mr N's discharge was appropriate. Mrs Q was dissatisfied with the outcome of the review.
Findings
The Ombudsman upheld both of Mrs Q's complaints. He found that a combination of system failures, poor recording of information by doctors, and an error in clinical judgment, had resulted in Mr N's inappropriate discharge. The Ombudsman also found confusion amongst both A&E and medical staff about the procedure for referring patients from A&E to the RMO. He found errors and omissions in the record keeping of the majority of staff who dealt with Mr N. In particular, the failure by the A&E registrar and consultant to record their presumptive diagnoses had resulted in the RMO who discharged Mr N not having a full picture of Mr N's clinical condition. The Ombudsman's clinical assessors advised, however, that despite the failure by A&E doctors to record their presumptive diagnoses, there was sufficient information in Mr N's medical records, in particular the administration by the A&E registrar of intravenous antibiotics, to indicate to the RMO that admission was required in order to confirm or disprove a presumptive diagnosis of meningitis.
Remedy
The Trust had reminded all staff of the need for all medical records to be accurate and complete and agreed to ensure that this reminder is acted upon. The Trust had also made changes to introduce a formal handover procedure for the referral of patients from A&E. The Trust agreed to put a protocol in place for staff having concern about the discharge of a patient, and to review the staffing arrangements and organisation of the medical team. The Trust apologised to Mrs Q.
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