Decision Report 201607122

Summary

Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken to Ninewells Hospital where he died that evening. Mr C noted from the post-mortem report that the cause of death was recorded as a massive gastrointestinal haemorrhage (bleed) and said that had this been identified during the first visit to hospital then the outcome may have been different.

We obtained independent advice from a consultant in emergency medicine about the treatment provided during the first attendance at hospital. We found that the assessment of the cause of Mr A's collapse was reasonable. We also found that the assessment of his head injury was reasonable. However, we found that an insufficient risk assessment had been made when considering Mr A's reporting of vomiting blood and as such he should have been admitted to hospital on the first attendance or kept in for a longer period of observation. However, even if this had been case we could not say with certainty that the outcome would have been different, but we acknowledged that Mr A would have had an earlier review by clinical staff. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation; and
• share our report with the relevant staff so that they can reflect on their actions.