NHS Lothian apologises after stroke patient not given CT scan despite being put on medical record

A health board has apologised after a stroke patient was not given a CT scan, despite it being put on their medical record.

The Scottish Public Service Ombudsman (SPSO) upheld the complaint against NHS Lothian’s acute division.

In its decision report, the SPSO said that the patient, referred to as C, complained that the board failed to provide them with reasonable care and treatment when they were admitted to an acute medical unit, specifically that they were discharged too soon and that there was a delay in diagnosing that they had suffered a stroke.

After taking independent advice from an adviser specialising in acute medicine, the watchdog found that the health board incorrectly documented that a CT scan had been carried out.

The patient should have remained in hospital to be assessed in more detail before they were discharged, the watchdog said.

The report said: “We found that more consideration should have been given to C’s symptoms and the possibility that they were related to a stroke.

“In particular, a CT scan should have been carried out earlier, which could have led to an earlier diagnosis and treatment with medication. On C’s readmission, C’s stroke was visible on a CT scan. It therefore was possible that a CT scan, on their first admission, could have shown C’s stroke.”

The ombudsman added that the patient’s nursing notes before their discharge lacked detail.

The health board apologised for the miscommunication which occurred between nursing staff in relation to C’s fitness for discharge and said that learning had been put in place for effective communication.

NHS Lothian said that this was communicated verbally and therefore there was no paper evidence.

The SPSO considered this to be unsatisfactory and upheld the complaint.

It recommended that NHS Lothian apologise to the patient for the failings identified and recommended that where a patient presents with neurological symptoms after a colonoscopy, consideration should be given to the possibility that they may be related to a stroke, that their suitability for discharge should be appropriately assessed and their condition appropriately reviewed to see if their symptoms settle and for relevant scans to be carried out prior to discharge.

The SPSO added that the rationale for a patient’s discharge should be properly documented with details of all relevant assessments fully documented. Information recorded in a patient’s records should be accurate.

Dr Tracey Gillies, medical director for NHS Lothian, said: “NHS Lothian has apologised to C for the failings identified. We have implemented the recommendations and reported back to the SPSO.”