A PATIENT who died days after he was denied hospital care because he had a learning disability has sparked a major review of NHS services in Lothian.
The Mental Welfare Commission for Scotland said the man was the victim of discrimination after a Royal Infirmary consultant declined to carry out an in-depth medical investigation because he assumed it would have caused the patient distress or led to a “deterioration of his behaviour”.
The investigation, the results of which have been sent to NHS boards across Scotland and are being examined by the Scottish Government, also found that poor communication between health professionals had meant vital warning signs that could have pointed doctors to diagnose the fatal condition were missed.
Dr Donald Lyons, chief executive of the Mental Welfare Commission for Scotland, said the conduct of the consultant who sent the patient home from hospital had struck a nerve with him personally.
That consultant no longer works for NHS Lothian.
“What bothered me most is that if it had been me going along to hospital with those physical problems, I think I would have received a far better service than he got,” Dr Lyons added.
“I think this man was treated less favourably because he had a learning disability. They didn’t get to the stage of thinking how can we best support this man. There seemed to be an assumption that being in hospital would distress him rather than thinking, ‘what does he need?’.
“Our experience is that this could happen anywhere – that an individual or small number of people either deliberately or unconsciously discriminate. As a society, we can’t tolerate that. It is important that all NHS boards look at this case.”
In June 2011, the patient had decaying teeth removed, despite a dentist warning the procedure placed him at risk of developing the rare heart condition endocarditis as he had disease of a heart valve and bacteria could enter his bloodstream through his mouth.
The patient, whose learning disability led to behavioural problems which saw him detained at the State Hospital in Carstairs after making threats to kill, became more unwell.
After losing a stone in weight, he was sent to the Royal by a psychiatrist, but a physician sent him back to the community unit he then lived in without performing X-rays, an ECG or urine examination. He was found dead four days later. A post mortem found he had died of endocarditis.
Despite the dentist warning of the condition and even giving staff who cared for the man a leaflet on endocarditis, symptoms were missed even as his physical health worsened. By the time the patient visited the Royal Infirmary and was dismissed, in September 2011, he may not have survived even if the infection was diagnosed.
NHS Lothian has apologised to the patient’s family.
Dr David Farquharson, the health board’s medical director, said: “A number of systems were put in place to prevent a repeat of similar circumstances. We continue to work with the Mental Welfare Commission for Scotland and agreed a set of actions to address the recommendations made by our internal review and by their organisation.”