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Mid and South Essex NHS Foundation Trust

P-003038 · Statement · Decision date: 31 October 2024 · View Mid and South Essex NHS Foundation Trust scorecard
Complaint (AI summary)
Trust did not appropriately assess Miss T's symptoms or call her MS nurse during ED visits, delaying infection diagnosis and treatment, which she claims almost caused her death.
Outcome (AI summary)
The complaint was closed. No evidence was found to indicate that assessments were inappropriate or that anything went wrong with the care provided.

Full decision details

The Complaint

4. Miss T complains the Trust did not appropriately assess her symptoms during visits to its ED on 20 January and 5 April 2023. She also complains it refused to call her multiple sclerosis nurse during the same visits.

5. Miss T says this delayed diagnosing and treating an infection, which almost caused her death. She says it has affected her speech, concentration and mobility. She said she does not feel listened to and feels she would not have been in the same position if it admitted her earlier. She wants service improvements.

Background

6. Miss T is a 67-year-old lady with a 25-year history of multiple sclerosis (MS). On 20 January 2023 Miss T visited her neurologist, and her partner noted new symptoms she had been experiencing for several weeks before. Her neurologist said they did not think her new symptoms were caused by her MS and requested further investigations to confirm the cause.

7. They advised her partner to contact 111 if she deteriorated. Later, on 20 January Miss T attended the Trust’s ED on the advice of 111. The Trust suspected her symptoms were due to her MS and sent her home.

8. On 21 January Miss T attended ED again after experiencing a seizure at home. She was admitted and treated for suspected encephalitis. Encephalitis is inflammation of the brain, usually caused by an infection. It is a rare but serious condition. It discharged Miss T on 21 February.

9. On 5 April Miss T attended the Trust’s ED again with similar symptoms to what she had been experiencing in January 2023. It admitted her and discharged her on 21 April following treatment.

Findings

12. 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.

13. Miss T says the Trust did not appropriately assess her symptoms during visits to its ED on 20 January and 5 April. She says it missed an opportunity to diagnose and treat her for encephalitis earlier, which led to her being admitted to the Trust’s ICU and she almost died. We were sorry to hear about Miss T’s experience. It is clear from what she has told us it has impacted her speech and mobility, which she feels would not have happened had it admitted her earlier.

14. GMC says if you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history and where necessary, examine the patient. It goes on to say promptly provide or arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs.

15. Miss T’s records show she attended the Trust’s ED, at 8.22pm on 20 January, concerned about new symptoms that possibly related to her MS which included intermittent confusion, blurred vision and shaking, along with reduced mobility and involuntary sniffing. It noted she had been experiencing the symptoms occasionally since 27 December. The Trust noted she was conscious and alert.

16. It assessed her at 9.20pm and went on to carry out a chest X-ray, blood and urine tests. The records show the Trust’s examination of Miss T showed no abnormalities and her results were normal. It discharged her home with advice to wait for the investigations requested by her neurologist earlier that day, and to return to the ED if her symptoms worsened. Which appears to be in line the GMC guidance above as we can see it recorded a history of her symptoms. It also promptly examined her, investigated her symptoms and provided advice.

17. It is understandable Miss T is concerned the Trust missed an opportunity to diagnose her with encephalitis on 20 January, as she returned to the Trust’s ED the following day after a seizure and was admitted to its ICU and treated for suspected encephalitis. From what she has told us it is clear it has had a long-term effect on her and she is still recovering now.

18. Our adviser explains encephalitis in its early stages is difficult to diagnose which can be made more difficult in patients with pre-existing neurological conditions. They say based on the information there is no evidence Miss T had clear signs of encephalitis when she presented at the ED on 20 January. The next day she had suffered a seizure which was a new symptom and led to the Trust reconsidering her condition.

19. We went on to consider another occasion when Miss T presented at the Trust’s ED on 5 April. The records show she attended the Trust’s ED at 1.30am with symptoms which she had been experiencing for one week including shaking episodes and slurred speech. It carried out an assessment at 7am and took note of her medical history which is in line with the above GMC guidance.

20. We can also see it carried out a scan of Miss T’s head and referred her for further investigations and management on a ward. It suspected she had a possible urinary tract infection and planned to carry out investigations to confirm this. Which also appears to be in line with GMC guidance to refer to another practitioner when it serves the patient’s needs.

21. Based on the evidence we have seen it appears the Trust followed GMC guidance when it assessed Miss T on 20 January and 5 April. We can see the Trust carried out detailed assessments during each visit and considered her symptoms and medical history. It also referred her for further investigation when needed on 5 April which led to treatment for a possible infection and further tests to assess the status of her MS.

22. Miss T is also concerned that the Trust refused to call her MS nurse when she presented at its ED on these occasions. We were sorry to hear this made her feel like the Trust did not listen to her and that she feels her nurse would have been able to explain her symptoms were not usual for her.

23. Our adviser explains there are no national guidelines that relate to a Trust contacting specialist nurses when a patient attends the ED. We cannot find any evidence in the records to suggest Miss T requested the Trust call her MS nurse on these occasions. However, our adviser explains it is important to note Miss T’s presentations at the ED on 20 January and 5 April were outside of normal working hours. They say it would normally be the case that nurse specialists are not available during these times. Therefore, the ED doctors would not normally attempt to make contact unless the patient presented within normal working hours.

24. It is clear from what Miss T has told us, she still does not feel like she has recovered from her admissions at the Trust and thinks she would not have been in same position had the Trust diagnosed her earlier. We do not wish to underestimate how difficult it must have been for her to relive these events and explain her complaint to us. We are grateful for the time and effort she has taken to do this.

25. We are satisfied the Trust did not get anything wrong and followed guidance when it assessed Miss T at its ED on 20 January and 5 April. We will therefore not take further action on this complaint.

26. Understandably from what Miss T has told us her experience has caused her great distress, and we are sorry to hear about this. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Trust has taken her complaint seriously.

Our Decision

1. We have carefully considered Miss T’s complaint about Mid and South Essex NHS Foundation Trust (the Trust). We were sorry to hear about the events that led to Miss T’s complaint. Understandably, she feels something went wrong when she attended the Trust’s emergency department (ED) as she was admitted to its intensive care unit (ICU) the following day where she told us she nearly died.

2. We have looked at the evidence Miss T and the Trust gave us. We were sorry to hear she feels the Trust did not properly assess her symptoms when she presented at its ED in January and April 2023. We have not found any evidence something went wrong with the assessments the Trust provided her with.

3. Therefore, we will not be taking further action on this complaint. We will explain our decision in more detail below. We hope the information in our statement gives Miss T some reassurances about what happened and explains why the Trust did not do anything wrong.

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