First attendance
13. Mrs C said her husband should not have been discharged from A&E after his first attendance on 20 February. We can understand why Mrs C thinks this. The medical records show the examination in A&E did not reveal any definite neurological abnormality and there was no clear diagnosis. However, taking the views of our advisers into account, we found the decision was in line with national guidance.
14. Mr C did not have the typical symptoms of a neurological emergency, such as a stroke. The medical records show the A&E doctor carried out a comprehensive assessment and ordered appropriate investigations, in line with the GMC guidance. This says a doctor should adequately assess a patient’s conditions, taking account of their history and symptoms, and promptly arrange suitable investigations. Our A&E adviser said the doctor’s actions were in line with this.
15. Our adviser said the doctor also acted in line with NICE Guideline CG150 by arranging a CT brain scan, which did not show any abnormalities. They discussed Mr C’s case with an A&E consultant before discharging him. The doctor gave safety netting advice, this is information given to a patient or their carer during a consultation, about actions to take if their condition fails to improve, changes or if they have further concerns about their health in the future. There is no evidence he needed acute hospital admission. For these reasons we found no failings in the decision to discharge Mr C.
Second attendance – A&E and AMU
16. Mrs C said during her husband’s second admission on 20 February, he was not treated quickly enough. She said the Trust only arranged an MRI scan at the point she demanded a second opinion.
17. Our A&E adviser said staff triaged Mr C within 30 minutes of arrival and a clinician saw him within an hour of the triage assessment. He explained the Trust appear to have used the MTS. This is one of the most commonly used triage systems. It gives a clinical priority to patients, based on presenting signs and symptoms, without making any assumption about the underlying diagnosis.
18. In line with this guidance, the Trust gave Mr C a category 3. The MTS recommends a patient should be seen within an hour. A doctor saw Mr C within that timeframe. Our adviser said there is no evidence to suggest Mr C required treatment any faster than this.
19. Our A&E adviser did not see any evidence that Mr C needed an MRI scan. We can see the Trust agreed to undertake one after Mrs C asked for a second opinion. We think it right the Trust took account of the views of the family, as the GMC guidance requires doctors to ‘respect the patient’s right to seek a second opinion’.
20. We asked our neurology adviser for his view about this and he agreed with our A&E adviser. He explained the records show staff observed Mr C to use his left arm and walk unaided, despite the reported weakness on his left side.
21. The Trust made a provisional diagnosis of functional disorder. Functional Neurological Disorders (FND's) is the name given to symptoms in the body which appear to be caused by problems in the nervous system, but which are not caused by a disease or disorder of the nervous system. Our neurology adviser agreed with this diagnosis. I have included additional information about function disorders in the annex to this report.
22. Our neurology adviser said Mr C did not need an MRI scan during this second attendance. He agreed Mr C may have needed further investigations, including an MRI brain scan and neurological opinion. NICE guidelines NG127 do not say this must be done during an acute admission, as such symptoms fluctuate over time. The guidance says ‘recurrent episodes of limb weakness are not uncommon in people with functional neurological disorders’.
23. As the A&E doctor had already advised Mr C to go to his GP to arrange further investigation if his symptoms did not resolve, it was in line with the guidance for the AMU to make the same decision. For these reasons we did not find any failings in the initial decision at the AMU to not carry out an MRI scan.
Pain medication
24. Mrs C said her husband was not given the right level of pain medication during both of his admissions to A&E, in the AMU and on the gastroenterology ward when he was first admitted. It is difficult for us to make conclusive findings about this, as some of the relevant records are missing.
25. We asked our A&E adviser about the pain relief given in A&E and the AMU and we used this advice to help us decide whether the Trust’s approach was in line with the RCEM guidance. We looked at each attendance in turn.
26. The Trust took a pain score when Mr C first arrived on 20 February, when he described severe pain. Staff gave him paracetamol and ibuprofen within 10 minutes of his arrival, at 11.40am. This was in line with the guidance which said pain relief for moderate and severe pain should be given within 20 minutes of arrival.
27. At 1.20pm the Trust gave Mr C diazepam, a mild sedative, and dihydrocodeine, a stronger painkiller. There is no documentation available recording any further assessment of Mr C’s pain following the first dose of painkillers and prior to administration of the dihydrocodeine.
28. The RCEM guidance says after receiving pain relief, a patient’s pain should be re-evaluated within 60 minutes for mild to moderate pain. According to the guidance he should have been reviewed 60 minutes after the 11.40am medication and 60 minutes after the 1.20pm medication. This did not happen and so this was a failing.
29. Mr C reattended at A&E the same day at 9.58pm. The records show staff triaged him at 10.28pm. The RCEM guidance says patients in moderate pain should be offered oral analgesia at triage and this did not happen.
30. The Trust offered paracetamol at 10.50pm, 22 minutes after triage and 52 minutes after arrival. This was not in line with RCEM guidance and so was a failing. However, we did not find this had an impact on Mr C as the records show he declined the pain relief offered a little later.
31. The Trust then gave Mr C dihydrocodeine and ibuprofen at 11:40pm, following the A&E doctor’s assessment. Staff gave him Oramorph (the oral version of morphine) at 12:45am on 21 February. Again, we have seen no documentation to show any pain assessment during this time. If this pain assessment did not take place, this is contrary to the RCEM national guidance quoted in paragraph 28 which outlines pain should be re-evaluated at least every 60 minutes.
32. Mr C moved to the AMU on 21 February and there are some records that show nursing staff considered his pain. The nursing records for 11am say ‘no complaints of pain’ and at 6pm say ‘analgesia given’. The records then show Mr C had a ‘settled night’.
33. A similar situation occurred on 22 February when Mr C was on the gastroenterology ward. The nursing records for that day said, ‘Patient alert and orientated, nil report of pain’.
34. We can see from these records that it appears Mr C’s pain was well managed for at least part of these periods. Again, there was no formal assessment or recording of pain, contrary to the GMC guidance which says, ‘adequately assess the patient’s conditions, taking account of their history’. This did not happen and so is a failing.
35. The loss of some of Mr C’s records means that we cannot know whether the Trust acted in line with the RCEM and GMC guidance in administering pain medication and assessing its effects.
36. There is also insufficient evidence to show the actions were in line with the GMC guidance. This says ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs’.
37. The complaint response said ‘The management of Mr C's pain relief whilst in the ED and in the AMU was appropriate and based on sound clinical judgement following careful consideration of all of your husband's presenting symptoms and scan images.’
38. The lack of records means we must conclude the Trust’s actions in relation to pain assessment and management fell below the standard expected by national guidance. This was a failing. We do not think the Trust has the evidence to reach the conclusion it did in the complaint response.
39. We agree that it appears the Trust did provide some pain medication and did carry out some assessments. However, we also accept Mrs C’s account that there were periods when her husband’s pain was not well controlled. For this reason, we uphold this part of the complaint.
Steroids
40. Mrs C said her husband was told he needed steroids following the MRI scan but then had to wait five days before these were prescribed. She said because of this delay, he suffered brain damage.
41. We asked our neurology adviser if the Trust should have prescribed steroids sooner. It was his opinion that Mr C should not have been prescribed steroids sooner as he was still having investigations into the cause of his symptoms.
42. The records show the Trust first discussed steroids on 22 February, writing they would ‘consider steroids’ after the test to collect spinal fluid (CSF test).
43. Our adviser explained treatment with steroids could have affected results of the CSF test. The Trust carried out the CSF test on the afternoon of 23 February and the doctor considered the results of the test 24 February.
44. The consultant again considered prescribing steroids on 26 February and wrote that they would not give ‘more improvement’ but might speed up his recovery. Mr C started steroids on 27 February.
45. We understand Mrs C’s concern that there may have been a delay, but we do not find this to be the case. The steroids were not delayed. They were part of a range of treatments that were being considered to help Mr C’s symptoms. It was after the CSF test and the review by the stroke consultant that the Trust made the decision to prescribe the steroids.
46. Our neurology adviser did not see a reason for the steroids to be prescribed sooner. He also said it was his view that earlier prescription of steroids would have made no difference to Mr C’s prognosis.
47. Taking into account the views of our adviser we found the decision making about the steroids was in line with the GMC guidance. This says ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs’.
Delay in diagnosis
48. We can understand why Mrs C is concerned the Trust was not been able to reach a definite diagnosis for her husband prior to his discharge on 26 April. She said he was treated for both a spinal cord stroke and inflammation.
49. Our neurology adviser agreed there is remaining uncertainty about Mr C’s condition. He also agreed Mr C had been treated both for a possible stroke, and was given aspirin, and for possible inflammation, and he was given steroids. Mr C showed symptoms of each of these conditions and our adviser said the Trust followed the correct management plan for him in line with the guidance below.
50. As Mr C’s symptoms changed and developed, the Trust assessed and treated him in line with NICE guidance 127. This says, ‘New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed as described in the relevant sections of this guideline.’ The guidance says doctors should explain to patients ‘that their symptoms are likely to fluctuate and evolve with time’. It explains that symptoms may need to be managed, rather requiring neurological intervention.
51. We did not find there to be any failings in the fact the Trust was not able to find a definitive cause of Mr C’s symptoms. Our adviser said this is a clinical situation often encountered in neurological practice.
52. He said the changes shown on Mr C’s brain scan are undiagnosed and are not sufficient to explain all his symptoms. He agreed with the Trust’s diagnosis of a functional neurological disorder. We have given details in the annex which explain why it is common that this disorder is difficult to diagnose.
53. We can see the Trust continues to investigate the cause of Mr C’s symptoms.