Decision Report 201508430

Summary

Miss C complained about the care and treatment received by her late father (Mr A). Mr A had an MRI (magnetic resonance imaging) scan at Forth Valley Royal Hospital to investigate leg weakness. The scan revealed an incidental finding of a six centimetre abdominal aortic aneurysm (AAA - a bulging of the aorta, one of the largest blood vessels in the body, which runs from the heart to the legs). This had not yet been shared with Mr A when he took unwell a few days later and, while being transported to hospital in an ambulance, he went into cardiac arrest and died. Miss C complained about the time taken to share and act upon the findings of the MRI scan.

The board informed Miss C that, in line with normal practice, the MRI was flagged for urgent reporting within two to three days. They explained that immediate intervention would only be arranged where there was evidence that the AAA had ruptured, which there was not in Mr A's case. They noted that the MRI was reported three days later and an urgent referral was made to the vascular team two days after that. This was the day of Mr A's death. The board noted that further tests would have been required and the national target for elective treatment of aneurysms is 42 days. They therefore considered that even if Mr A had been referred to the vascular team on the same day as the MRI scan, it would have been a few weeks before he received treatment.

We took independent medical advice from a consultant physician. They noted that, while they could not be certain of the cause of death, the risk of the AAA rupturing was low and that the board attributed Mr A's death to a heart attack. They noted that Mr A did not have any symptoms suggestive of a rupture at the time of his scan and they considered that the scan was reported and acted on within an appropriate timeframe. We accepted this advice and concluded that the outcome could not reasonably have been prevented.