Decision Report 201302204

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mr A) about a failure by staff at Monklands Hospital to properly assess and diagnose him after he attended the A&E department on two separate occasions. Mr A was initially diagnosed with a possible faint or seizure, with anxiety as the possible cause. He was discharged home and a referral made for him to attend a seizure clinic. Mr A then went to see his GP who referred him back to hospital, where he was admitted to intensive care and diagnosed with TB meningitis (an infection of the tissues covering the brain and spinal cord). Mr C had a very slow recovery and has been left with long term debility.

After taking independent advice from a medical adviser, we identified that there were shortcomings with the observations carried out on Mr A during both hospital visits. The board acknowledged that it was unacceptable that staff did not take Mr A's temperature during his first visit or repeat his observations when it was noted that his blood pressure and heart rate were raised. However, although we were critical of these omissions we did not consider that they were significant failings overall, nor were they likely to have led to an earlier diagnosis or different outcome. Our adviser said that TB meningitis is a very rare condition, and it was not unreasonable of the medical staff to attribute Mr A's symptoms to more common conditions such as anxiety and epilepsy. We concluded that the actions taken by staff were reasonable and in accordance with national guidelines. The board also showed us evidence that they have reviewed the observations procedure in the A&E department and made changes to ensure that the failings do not recur.

Recommendations

We recommended that the Board:

• apologise to Mr A for the failings in relation to his observations when he attended the hospital on two separate occasions.