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Case ref:201704552
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Date:July 2018
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C attended the emergency department of Glasgow Royal Infirmary twice with severe abdominal pain. On both occasions, Mrs C was told she had stomach flu and was discharged home. Mrs C's GP decided to refer her to the hospital's surgical department, as she was still in severe pain. She was then found to have a hernia (a condition where an internal part of the bodypushes through a weakness in the muscle or surrounding tissue wall) in her stomach and a small bowel obstruction.
Mrs C complained that the board failed to give her appropriate care and treatment during her two attendances to the emergency department. Specifically, Mrs C complained that she was misdiagnosed with stomach flu and was not given appropriate pain relief.
We took independent advice from a consultant in emergency medicine and from a nurse. We found that all appropriate investigations were carried out into Mrs C's condition on both occassions. On the basis of those investigations, we considered that it was reasonable that Mrs C was diagnosed with stomach flu. However, we found that Mrs C's pain level was not appropriately assessed or recorded and that there was an unreasonable delay in giving her pain relief medication. Therefore, we upheld Mrs C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mrs C for the failure to appropriately assess and record her level of pain, and for the delay in giving her pain relief medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- Pain levels should be assessed and recorded appropriately. Timely and appropriate pain relief should then be provided to patients, and staff should check with patients whether they require pain relief medication.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.