Decision Report 201508345

Summary

Mr C, who works for an advice and support agency, complained on behalf Mrs A. Mrs A's husband (Mr A) was suffering from neck pain and had also experienced some episodes of blood in his urine. He attended at the A&E department of Inverclyde Royal Hospital and was also attending the urology out-patient clinic following a referral from his GP. Mr A was diagnosed with a muscular neck condition at two emergency department attendances. The blood in his urine was considered to be connected to a medicine he was taking to help prevent blood clots. Mr A was later admitted to the hospital via the A&E department and was subsequently diagnosed with lung cancer which had spread to the vertebrae in his neck.

Mr C complained about the care and treatment that Mr A had received as Mrs A felt that his condition could have been diagnosed earlier if appropriate tests had taken place.

After taking independent advice from a consultant in A&E care, a respiratory consultant and a urology consultant, we upheld this complaint. Whilst no failings were identified in relation to the urology investigations or the care that Mr A received following his admission and diagnosis with lung cancer, we found that there had been issues in the two attendances at the A&E department. The advice we received was that the diagnosis that Mr A had received was not reasonable and that other issues had not been appropriately considered. The A&E adviser highlighted that after Mr A's second attendance, it would have been reasonable to discuss his case with more senior doctors.

Recommendations

We recommended that the board:

• apologise for the failings in care provided by the A&E department during Mr A's two attendances;
• ensure that the findings of this investigation are discussed at the next appraisals of the relevant clinicians; and
• review the procedure for escalation to senior staff for patients presenting at emergency departments with progressive symptoms or signs.