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Case ref:201401773
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Date:April 2015
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Body:Lothian NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C complained that her daughter (Miss A) was incorrectly diagnosed with a viral infection when she was seen by a doctor at the Royal Hospital for Sick Children. Ms C explained that three days after they attended the hospital Miss A was diagnosed with bacterial pneumonia whilst on holiday abroad.
We took independent advice from one of our medical advisers, who said that the diagnosis of a viral infection was reasonable as there was no clear evidence of pneumonia when Miss A attended hospital. We identified that the doctor obtained relevant information about Miss A and that the examination carried out was in line with national guidance. On this basis, we did not uphold the complaint but we found that there were no records to show that Miss A's level of consciousness had been assessed using the Glasgow coma score (a scale for recording the conscious state of a person) or whether the doctor had given any advice to Ms C on what to do if Miss A's condition did not improve, or deteriorated.
Recommendations
We recommended that the board:
- ensure the staff involved in Miss A's care reflect on the adviser's comments regarding the Glasgow coma score and advice to patients and/or their relatives.