Decision Report 201507697

Summary

Mr C, who works for an advocacy and support agency, complained on behalf of his client (Mr A). Mr A attended the A&E department at Glasgow Royal Infirmary where he was assessed as having had a transient ischemic attack (TIA), a condition where the blood supply in part of the brain is temporarily disrupted. After being assessed, Mr A was discharged with aspirin and a referral for an appointment at the TIA clinic. However, Mr A had a stroke the following day and was readmitted to the hospital. Mr C complained that Mr A should not have been discharged and that the doctor who had assessed Mr A on his first admission had failed to note that he had on-going symptoms which would have indicated admission. Mr C said that Mr A was concerned that he could have suffered a more severe stroke as a result of the discharge the day prior to his stroke.

We took independent advice from a consultant in emergency medicine. We found that the doctor performed reasonable observations of Mr A during his attendance at A&E. However, the adviser found that the doctor who assessed Mr A had not recorded the time of onset, or the duration, of Mr A's symptoms. The adviser was critical of this but said that whilst this information may have led to Mr A being admitted rather than discharged, it was not possible to say if admission would have prevented his stroke.

Recommendations

We recommended that the board:

• remind A&E staff of the need to accurately assess and document the nature and duration of TIA symptoms and report back to this office on action taken; and
• apologise to Mr A for the failure to accurately assess and document his TIA symptoms.