Failure to diagnose in SDEC
25. 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 the Trust did anything wrong at this point.
26. Miss L said she attended SDEC at the end of September 2023, having experienced a severe headache for several days. She told us she was in significant pain. She complains no one listened to her and acknowledged the pain she was in. She said she was unable to stay there because the unit was bright, and she was experiencing photophobia. Photophobia is an abnormal sensitivity to light causing discomfort and pain.
27. Miss L said SDEC staff talked about the possibility of blood tests but suggested she had a tension headache. She self-discharged due to the pain.
28. In its complaint response, the Trust said the SDEC team were treating Miss L for a tension headache but had considered other possible diagnoses. They ordered blood tests and a computed tomography (CT – a computer guided X-ray) scan of her head to check for a bleed in the brain.
29. The Trust said records indicate Miss L was tearful but did not want to engage with staff and left the department after taking paracetamol.
30. GMC guidance 16b says, ‘provide effective treatments based on the best available evidence’.
31. GMC guidance 18 says, ‘you must make good use of the resources available to you’.
32. GMC guidance 21 says, ‘clinical records should include: a) relevant clinical findings b) the decisions made and actions agreed, and who is making the decision and agreeing the actions, c) the information given to patients d) any drugs prescribed or other investigation or treatment e) who is making the record and when’.
33. We can see from records Miss L attended the SDEC complaining of a headache. We can see she was assessed and later the same day she left the department.
34. We asked our ED adviser whether staff at SDEC acted in line with guidance when Miss L attended, or whether they should have provided different treatment given her presentation and what she was saying.
35. Our ED adviser said clinical records indicate staff acted in line with good medical practice. They completed a clinical assessment and our adviser felt this was thorough and well documented. The attending consultant planned to arrange blood tests and organise a CT head scan to check for any potential disease or abnormal issues within the brain. Staff also prescribed a prescription of pain analgesia (pain relief).
36. We can see unfortunately Miss L left the department before the team could complete investigations or make a formal diagnosis. Notes indicated Miss L had the mental capacity to make this decision.
37. We have not identified any failings in the care or treatment provided to Miss L at SDEC. We understand she found the pain overwhelming and the environment too uncomfortable to stay in. We realise this must have been a distressing situation for her. We cannot say the team did not act within guidelines. We will not be looking further at this part of her complaint.
Failure to test in ED
38. Miss L told us she returned home and was projectile vomiting. She contacted 111 who advised her to attend SDEC. She was reluctant to return because she felt she had been dismissed previously. She said by this point she had pain penetrating down her spine. She attended the ED.
39. Miss L complains that the team at ED delayed appropriate testing which led to a further delay in treatment.
40. The Trust says when Miss L attended the ED, the team suspected tension headache which impacted on the treatment it provided at this point.
41. BMJ guidance describes the symptoms and signs of viral meningitis: ‘headache and fever are typically prominent. Patients may also describe photophobia, neck stiffness and nausea’.
42. We know Miss L was presenting with a headache, photophobia and nausea. We can see from records the team assessed her on admittance for a severe headache. She is reported to be alert and her observations were normal. The team carried out a neurological assessment. This is an assessment of the nervous system’s function aiming to identify any abnormalities or damage. The examination did not show any concerns.
43. The team organised a CT scan which was normal and referred her to the medical team.
44. We asked our ED adviser whether the team took the correct approach in Miss L’s care given her symptoms and presentation. They said the management of her care in the ED was appropriate.
45. They said her presentation was not entirely typical of a patient presenting with meningitis, noting she did not have a fever and her observations were normal. They feel the team took the right approach by considering other causes of the headache such as intracranial bleed (a bleed within the skull). They were also considering the possibility of viral encephalitis. This is an inflammation of the brain caused by infection.
46. We can see Miss L was assessed the next day by the medical team. We can see they documented a thorough history and examination. At this point, they were considering encephalitis and migraine. They started Miss L on acyclovir.
47. Our ED adviser said it was good practice to start Miss L on acyclovir at this point. They note she had photophobia and a worsening headache, symptoms of viral meningitis. They said acyclovir is prescribed for encephalitis but also covers viral meningitis.
48. We know Miss L’s pain was persisting and increasing. We understand how awful this must have been for her. We consider the team at ED acted in line with guidance and treated her appropriately.
Inadequate communication
49. Miss L told us during her admission, she was told inaccurate information about her treatment. She was particularly concerned information was withheld from her with regards to her CSF white cell count. An increase in a white cell count can indicate viral meningitis. She said the team did not accurately communicate the reasons for delays in receiving test results.
50. The Trust has apologised for some areas of communication. It apologises for not communicating sufficiently with her about their reasoning around treatment when she was admitted to the clinical assessment unit (CAU).
51. It says information was not withheld from he about the CSF white cell count. It explains there were some issues with the sample which led to a delay in the processing and so in obtaining results.
52. GMC guidance says, ‘healthcare providers should support patients in making informed decisions about their care by providing clear and accessible information. This includes discussing treatment options and respecting patients’ rights to seek second opinions’.
53. The records do not detail what was explained to Miss L or what discussions occurred.
54. We can see from the records there are a few entries indicating Miss L was upset with the medical teams and told them she felt she had not been kept informed. Her main concern in these conversations were that the team did not discuss the diagnostic uncertainty with her, did not inform her about the CSF white cell count, reasons for delay in the anti-viral treatment and the provision of analgesia.
55. We can see the relevant teams apologised and attempted to deescalate and explain the complexities of the case.
56. We asked our neurologist adviser whether they considered the team had communicated appropriately with Miss L about her treatment during her admission.
57. They identified there was diagnostic uncertainty in Miss L’s case. She presented with non-specific symptoms such as headaches, nausea, vomiting and photophobia. They identified there was no concerning signs on examination such as swollen optic disc, fever or obvious meningism. Meningism refers to a set of symptoms which is often seen in meningitis.
58. They explained diagnostic is a nuanced aspect of clinical medicine and requires careful judgement and communication to covey. They referred to research which talks about complexities of explaining diagnostic uncertainty, which can potentially increase the anxiety of the patient, while there is no definite diagnosis.
59. They felt the medical team was right not to be concerned and to refer to neurology for clarification. We cannot say from the medical records if this uncertainty was conveyed to Miss L.
60. With regards to Miss L’s complaint about the withholding of information about the white cell counts, our neurologist adviser said it is not always possible for ward teams to know where specific samples are and how far along the analysis process they are.
61. We can see in this case the results were not available on the Monday although the samples had been sent off on the Friday evening. Our adviser said, in many Trusts, when a sample is taken out of hours, it is transferred to a centralised laboratory which means it can take longer to analyse and report.
62. We cannot see from records staff communicated this process to Miss L at the time the sample was taken.
63. We understand Miss L’s presentation was relatively complex and there was diagnostic uncertainty. We consider Miss L should have been informed about the possible diagnosis and reasons for any delays in getting tests results. Due to the information contained in the records, we will not be able to reach a satisfactory conclusion about all the discussions.
64. We can see evidence of some discussions, and Miss L expressing her frustration. We understand how frustrating and worrying this situation was for Miss L. We consider the team missed opportunities to share information with Miss L. We cannot say this impacted on her clinical care. We can see the Trust has apologised for lack of communication. We will not be taking this part of her complaint further.
Provision of pain medication
65. Miss L complains about the provision of pain medication throughout her admission. She said she was not giving regular pain medication and had to request this frequently. She said there were long periods throughout the days when nurses did not administer pain medication and she was in severe pain. We understand this must have been an awful experience for Miss L.
66. The Trust has not responded fully to Miss L’s complaint about pain medication. In its response it refers to two days of admission. It says on one of these days her pain assessment chart documented no pain three times a day, and on another day Miss L reported moderate pain and she was provided with pain medication.
67. The WHO pain ladder guidance is based on the principle that pain should be managed by administering drugs regularly and on demand as needed. It says, ‘analgesics should be administered on a regular schedule to maintain consistent pain control’.
68. We can see from the nursing and medical records Miss L was asked about her pain and offered pain relief. Records indicate Miss L rated her headache in the moderate to severe range. The pharmacy records indicate analgesics were prescribed and available.
69. We asked our neurology adviser whether the team managed Miss L’s pain appropriately and in line with guidance.
70. They noted instances where there was a delay in administering analgesic. They said pain medication should be given on time in order to minimise patient suffering. They said there can be extenuating circumstances on a busy ward and this is not top priority. We do not know whether this was the case for Miss L.
71. Our adviser recognised pain is a subjective matter but highlighted poor pain management can exacerbate a patient’s distress, reduce quality of life and increase likelihood of issues such as anxiety and depression. They also said insufficient analgesic treatment can hinder recovery and rehabilitation.
72. We consider there are indications of failings with regards to pain management. We know Miss L was experiencing severe pain through a relatively lengthy admission and consider the team should have provided her with pain relief more regularly and without her need to prompt.
73. Miss L is seeking an apology and service improvement. We have approached the Trust and proposed a resolution to resolve this aspect of Miss L’s complaint. The Trust has agreed to write to Miss L to apologise for this failing. It has also agreed to write to Miss L and to us to advise us how it ensures patients are given pain medication as required.
Delay in treatment
74. Miss L says the Trust inaccurately documented her anti-viral medication. She complains she was started on antiviral medication, but this was stopped. This was restarted after the diagnosis, but the virologist believed she had already received five days of medication when in fact she had only received two doses.
75. Miss L is concerned that the delays in tests, the obtaining of results and the confusion around the medication all led to a delay in diagnosis and treatment.
76. We can see from pharmacy records Miss L did not receive anti-viral medication between 2 and 7 October. We can see acyclovir was initiated as soon as there was a concern of viral meningitis. The second dose was unsuccessful due to the cannula tissuing and she did not receive any further doses over the next five days. Cannula tissuing is irritation caused by a cannula, which is a small tube or needle inserted into the vein.
77. Our adviser said since there was still a clinical concern of infection, staff should have re-sited the cannula and continued with the acyclovir medication.
78. Their view is that the gap in treatment would not have had a long-term impact. However, they said had she been given the anti-viral medication during that time, it could have shortened her inpatient stay. They told us there is currently no direct evidence that delaying this treatment increases the risk of developing chronic fatigue syndrome.
79. We consider there is an indication of failings with regards to this aspect of Miss L’s complaint. In line with trying to resolve Miss L’s complaint, we approached the Trust about this also. It has agreed to apologise for the gap in Miss L’s treatment and to explains how medication is accurately documented.
80. Our principles of good complaint handling talk about putting things right. They say there is a wide range of appropriate response to a complaint that has been upheld, ‘these include: an apology, explanation and acknowledgement of responsibility’. We are satisfied these actions will resolve Miss L’s complaint and in a timelier way.
81. We are sorry to hear about Miss L’s experience in hospital and the pain she was experiencing. We are sorry to hear this has continued after her discharge. We hope she continues to improve and wish her well for the future.