14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
Dismissal of symptoms, self-discharge, and accuracy of record/complaint response
15. Mrs T complains the Trust dismissed her and did not take her symptoms seriously when she attended A&E on 2 August. Mrs T complains the Trust advised it wanted to admit her in its complaint response, but she discharged herself. Mrs T says this is incorrect.
16. During our telephone call, Mrs T told us she suffered pain between 2 and 18 August. She told us she relied on her husband’s diazepam for pain relief and self-arranged for a private physiotherapist to review her. Mrs T told us her symptoms were so severe, an ambulance attended and took her to an alternate hospital. Mrs T also told us she was diagnosed with gluten ataxia and stiff person syndrome.
17. We were sorry to hear of how Mrs T suffered, and of the distress she experienced. Mrs T also told us the Trust’s complaint response added to her distress, as no one communicated the decision to admit to her at the time. It must have been scary for Mrs T to experience these symptoms and feel the Trust were dismissing her.
18. To address Mrs T’s concerns, we reviewed the relevant medical records and the Trust’s discharge policy. The policy states discharge of patients from A&E and minor injuries requires the patient to be safe to be discharged with an appropriate amount of care and safety netting in place. Patients should be given any necessary information leaflets, signposted towards other services, and clinicians should highlight any red flags.
19. The most relevant part of the Trust’s discharge policy is on discharge prior to clinical recommendation (discharge against medical advice). We have noted the overall policy document was updated in January 2024, after the events of this complaint. However, this most relevant section was from January 2012. We therefore consider it was in place at the time of Mrs T’s visit and so relevant for us to consider.
20. The Trust’s policy presumes all patients are stakeholders in their own care and should be fully informed about their treatment plan to ensure they are able to make an informed decision regarding the treatment they receive. Some patients may choose not to complete and/or follow the clinically recommended treatment plan and may opt to leave the hospital prior to receiving either part or all of their treatment.
21. Principle one of the Mental Capacity Act (2005) details that a patient should be presumed to have mental capacity unless concerns are raised that they may not be able to understand, retain, use, and weigh important information or communicate their decision in order to give valid informed consent.
22. GMC guidelines state in providing clinical care, clinicians must provide effective treatments based on the best available evidence, take all possible steps to alleviate pain and distress, and consult colleagues where appropriate. GMC guidelines also state the documents clinicians make (including clinical records) to formally record their work must be clear, accurate, and legible. Clinicians should make records at the same time as the events they are recording or as soon as possible afterwards.
23. The medical records show at 11.44am on 2 August, Mrs T attended A&E with worsening symptoms of swelling on her feet and legs and unable to bare weight on her right leg.
24. At 3.14pm, an emergency medicine consultant examined Mrs T. They noted in the records she had good power her lower leg but were unable to assess the power in the upper leg due to the pain. They took X-rays of the right femur and hip and offered analgesia (pain relief).
25. At 4.45pm, the consultant reviewed the X-rays and noted no skin changes or tenderness. They discussed Mrs T’s case with orthopaedics. They took bloods and offered a trial of nefopam (pain relief). They noted if no active disease showed in the results, they would aim to send home with a GP follow up. If Mrs T was unable to get home, they would admit to acute medicine.
26. At 6.53pm, the consultant asked about Mrs T and noted she was still in pain. They noted the pain appeared related to spasms and contradictions of quad muscles. They reviewed the X-rays again and offered oral ibuprofen and diazepam. They wrote in the records they planned to admit to acute medicine if Mrs T’s symptoms did not improve.
27. At 8.30pm, the Trust noted Mrs T had ongoing significant pain and remained unable to mobilise. It wrote in the records it decided to admit her.
28. At 8.49pm, the Trust noted Mrs T wished to go home and was able to mobilise slowly. It provided codeine with advice to follow-up with her GP. It discharged her at 9.05pm.
29. In this case, the Trust examined Mrs T and performed investigations into her symptoms in line with GMC guidelines. It took X-rays, bloods, and consulted with orthopaedics for a possible cause. It also provided analgesia to alleviate Mrs T’s pain and distress. It had already ruled out DVT a few days before.
30. The records indicate the Trust planned to admit Mrs T for further investigation and noted this intention at 4.45pm, 6.53pm, and 8.30pm. At 8.49pm, it noted Mrs T wished to go home and did not want to stay for a medical review.
31. We have carefully weighed all the evidence to come to our decision. On balance, we think the evidence indicates the Trust attempted to explore the reasons for Mrs T’s symptoms whilst she was in A&E and planned to admit her for further investigation and observation.
32. We also cannot say what further investigations the Trust would have carried out had it admitted Mrs T. For this reason, we consider the Trust acted in line with GMC guidelines in its initial planned treatment of Mrs T’s symptoms. We can see no indications of failings on this issue.
33. In its complaint response, the Trust provided an overview of Mrs T’s attendance on 2 August. It explained the results of the X-ray and bloods were normal. It noted no immediate neurological emergency was detected. It explained the doctors planned for a medical admission and further observation and investigation, however, Mrs T decided to go home.
34. Mrs T stated to us on 26 February 2023 and via email to the Trust on 16 November 2023 that at no point did the Trust offer to admit her. She states she would have jumped at the chance to be admitted.
35. To address this, we considered our principles and the NHS Complaints Standards. Our principles state public bodies should create and maintain reliable and usable records as evidence of their activities. The NHS Complaints Standards states staff should give a clear, balanced account of what happened based on established facts.
36. In this case, the Trust has recorded its decision to admit on three occasions. The Trust noted it could not falsify this record without leaving an audit trail and that the notes were contemporaneous. As Mrs T’s account conflicted with this, we asked if she had any contemporaneous evidence that may suggest the decision to admit was not communicated with her. Mrs T advised she did not.
37. Based on the evidence we considered, we think it is more likely than not the Trust planned to admit Mrs T. Based on this, we can see no indications of failings in how the Trust recorded its plan to admit her. We recognise Mrs T’s account conflicts with this and wish to acknowledge the distress she has felt regarding this issue.
38. The medical records record the plan to admit Mrs T. This is in line with GMC guidelines, as well as our principles. They also document Mrs T’s desire to go home. The Trust’s discharge policy presumes all patients are stakeholders in their own care and presumes all patients have mental capacity to make decisions. The Trust therefore acted in line with its own discharge policy in allowing Mrs T to leave.
39. In summary, we can see no indications of failings in how the Trust recorded its decision to admit Mrs T. It recorded contemporaneous notes in line with GMC guidelines and our principles. We have found no evidence to suggest the Trust’s records are inaccurate. It, therefore, seems the Trust based its complaint response on established facts to give a clear account of what happened.
40. We were sorry to hear of the impact Mrs T suffered, and of her neurological diagnoses of gluten ataxia and stiff person syndrome. We wish her all the best in her future treatment and recovery. We also wish to thank her for bringing this complaint to our attention.
41. We have carefully considered the evidence provided. Based on this, we have seen no indications that anything went wrong regarding how the Trust approached its initial investigations and treatment of Mrs T’s symptoms.
42. We have also seen no indications that anything went wrong regarding the Trust’s decision to admit Mrs T and the accuracy of complaint response. We acknowledge this decision may add to Mrs T’s distress, but hope our explanation provides some reassurance to her moving forward.