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Case ref:201203099
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Date:May 2013
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Body:Borders NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C has type 2 diabetes. In July and August 2012 she attended, or was admitted to, hospital five times with swollen, painful legs. Deep venous thrombosis (DVT - a blood clot in a vein) was discounted and she was ultimately diagnosed as having cellulitis with some pitting oedema (an indentation on the skin that persists for some time after the release of pressure). After her last discharge, her GP advised her to stop taking the medication she had been prescribed, as she had neither DVT or cellulitis. He prescribed diuretic tablets (drugs that enable the body to get rid of excess fluid) which, Ms C said, remedied the problem. Ms C complained that the board failed properly to diagnose her condition and that she had been wrongly treated for cellulitis. She said that if the correct diagnosis had been made earlier, she would have improved sooner and spared unnecessary pain.
As part of our investigation, we obtained independent advice from one of our medical advisers. We carefully considered all the complaints correspondence and Ms C's relevant clinical records. The adviser said that, while the treatment given to Ms C was not unreasonable, overall there appeared to be a lack of clinical awareness. He said that although, throughout, she had pitting oedema, which indicated that diuretic therapy should be tried, it was not. The adviser said that if this had been tried earlier, it would likely have resolved Ms C's problem.
Recommendations
We recommended that the board:
- apologise to Ms C for failing to appropriately assess and treat her; and
- conduct a critical incident review into the circumstances in this case.