Decision Report 201305098

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.