NHS board apologise for diagnosis failure

NHS Borders, Newstead
NHS Borders, Newstead

NHS Borders has been forced to apologise after failing to correctly diagnose an elderly man who had suffered a stroke.

The widow of the man, who is referred to as ‘Mrs C’ in official documents, complained to the Scottish Public Services Ombudsman (SPSO) after her husband, ‘Mr A’, was admitted to Borders General Hospital and diagnosed with pneumonia.

Mr A was subsequently discharged from the hospital but later had a brain scan which showed he had suffered a stroke.

He was quickly readmitted to the hospital, but his condition deteriorated and he died several weeks later.

His widow complained to the SPSO about the medical treatment and nursing care that Mr A received, and complained that the board failed to reasonably monitor his replacement heart valve on a six-monthly basis, as previously agreed.

An SPSO spokesperson said: “We took independent advice from a consultant geriatrician (a doctor who specialises in the medicine of the elderly) and a nurse.

“In relation to Mr A’s medical treatment, we found that there had been a lack of continuity during his first admission, which contributed to the fact that the significance of the deterioration in his cognitive function and incontinence was missed, despite the family highlighting this.

“Whilst much of the communication with his family had been reasonable, there was a failure to listen to the family’s concerns at that time.

“We also found that it was unreasonable that a CT scan was not carried out during this admission, although we could not say whether or not this would have diagnosed Mr A’s stroke. Therefore, we upheld this aspect of Mrs C’s complaint.”

The SPSO also upheld the complaints about the nursing care Mr A received, finding that nursing staff had failed to review his cognitive impairment on an ongoing basis and to involve his family in the planning and review of his care.

Furthermore, the SPSO upheld Mrs C’s complaints regarding Mr A’s heart valve, finding that the board had failed to monitor Mr A’s replacement heart valve on a six-monthly basis.

Responding to the contents of the report a spokesperson for NHS Borders said: “The Scottish Public Services Ombudsman findings highlighted that some aspects of care that the man received were unacceptable.

“We have accepted the recommendations identified in full and have started to make the changes required so that similar experiences are avoided in the future.

“We are very sorry for the additional upset that our failings have caused the man’s wife and her family at an already difficult time and have offered a full apology.”

The SPSO has also given NHS Borders a list of requirements the health board must now implement.

In future, all patients admitted to the hospital and showing cognitive impairment must be given a brain scan, and patients with a serious chronic condition should receive follow-up care as agreed.

Furthermore, where it is decided to stop the follow-up appointments for a patient, the patient should be informed of this and the reasons for this.

NHS Borders has been ordered to follow up with the ombudsman and provide evidence of implementing these requirements.