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Failings in nursing care and delayed diagnosis

Summary 1100 |

Mrs F experienced poor standards in some aspects of her nursing care. A clinical diagnosis was delayed because facts were not thoroughly considered.


What happened

Mrs F went to A&E with unsteadiness, tingling and numbness in her feet. She left before tests were completed but was soon admitted to the Trust as an emergency with similar symptoms. Doctors suspected that Mrs F might be suffering from Guillain-Barre Syndrome (a rare and serious condition of the peripheral nervous system). 

The next day in hospital Mrs F developed a pressure sore. A scan then revealed a lump on Mrs F's spine and she was discharged to another trust for treatment. 

The complaint to us was about the standard of care, the lack of an earlier diagnosis and the pressure sore. Mrs F's daughter said that the failings had led to a tumour paralysing Mrs F from the waist down.

What we found

We upheld parts of this complaint. The Trust failed to follow national guidance on carrying out physical observations. Mrs F's nutritional care was poor but her pressure sore was properly managed. Given her age, history and symptoms, clinicians should have considered the possibility sooner that the cause of Mrs F's partial paralysis was a lump on her spine.

Putting it right

The Trust apologised for the nursing failings and developed an action plan to avoid a recurrence. It also asked the clinicians involved to reflect on the decisions made at the time and whether they might reasonably have also considered the possibility that Mrs F was suffering from a lump causing pressure on her spine.

Health or Parliamentary
Health
Organisations we investigated

Dorset County Hospital NHS Foundation Trust

Location

Dorset

Complainants' concerns ?
Result

Apology

Recommendation to learn lessons or draw up an action plan