NHS Lothian discharged stroke victim after head knock

Ms A was rushed to the emergency department at St John's Hospital. Picture: Lisa Ferguson
Ms A was rushed to the emergency department at St John's Hospital. Picture: Lisa Ferguson
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NHS Lothian has been told to apologise to a woman after staff twice failed to acknowledge she’d suffered from a series of strokes.

The Scottish Public Services Ombudsman has published its investigation findings following a complaint from the sister (Ms C) of the patient who sustained a head injury in a 
climbing accident. The woman, referred to as Ms A, initially attended hospital following the incident last year and was kept overnight before being discharged the following morning.

Ms A then became unwell and was visited at home by an out-of-hours GP before being rushed by ambulance to the emergency department at St John’s Hospital.

She was diagnosed with post-concussion syndrome – when concussion symptoms last up to months after the injury – and was again discharged home.

But Ms A continued to feel unwell and was subsequently admitted into hospital for a third time where she was eventually diagnosed as having had a series of mini strokes.

This led to Ms C lodging a complaint to the SPSO stating that NHS Lothian failed to provide appropriate care and treatment for Ms A and unreasonably discharged her from hospital.

As part of the investigation, the Ombudsman took advice from a number of experts including a consultant in emergency medicine, a consultant with experience in stroke medicine and a radiologist.

The decision report identifies there were two documented symptoms which should have prompted emergency staff to consider a stroke diagnosis for Ms A.

They also found Ms A should not have been discharged from hospital and that her working diagnosis should have been stroke, not post-concussion syndrome. Therefore she should have been referred to the hospital’s stroke 
team.

The SPSO recommended NHS Lothian apologise to Ms A and Ms C while stating emergency staff should note key symptoms to reach an appropriate diagnosis.

They also highlighted that complaints should be fully and appropriately investigated in the future.

Dr Tracey Gillies, medical director at NHS Lothian, said: “We are committed to providing high quality care to all our patients and recognise that there were failings in the care and treatment provided to Ms A. We have apologised to Ms A and Ms C for these failings, we accept the Ombudsman’s report, and we have acted on its recommendations to ensure lessons are learned.”