Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her by Accident and Emergency (A and E) staff which resulted in her being misdiagnosed and discharged only to be readmitted hours later suffering from bacterial meningitis and septicaemia.
Specific complaints and conclusions
The complaints which have been investigated are that following her admission to A and E on the morning of 11 January 2008 Grampian NHS Board failed to:
- (a) properly monitor and record Mrs C's condition (upheld);
- (b) supervise the actions of junior staff (upheld); and
- (c) provide Mrs C with appropriate transport at discharge (not upheld).
Redress and recommendations
The Ombudsman recommends that Grampian NHS Board:
- (i) undertake an audit (or provide evidence of a recent audit) of the quality of clinical documentation in A and E, with particular reference to discharge documentation;
- (ii) review their practice in relation to patient call buzzers being removed and consider how patients can summon assistance from staff when required;
- (iii) use events of this case to remind frontline staff of the importance of early diagnosis of meningitis and use in teaching for new junior doctors and nursing staff; and
- (iv) stress the importance of documenting consultation outcomes and requests for senior review to all grades of staff in the A and E department.
The Board have accepted the recommendations and will act on them accordingly.