The Ombudsman investigated Mr A’s complaint about the care he received in September 2021 after he presented at an Emergency Department (“ED”) with a severe headache.
The investigation considered whether the following were clinically appropriate: • the diagnosis, which resulted in a lumbar puncture (a thin needle inserted into the lower spine to remove fluid) • the consent process for the lumbar puncture • the lumbar puncture practice, given that Mr A has a condition which affects his ligaments • the decision to use a lumbar puncture instead of other diagnostic procedures • the aftercare following the lumbar puncture.
The investigation found that the actions of the Health Board were clinically appropriate. The decision to undertake a lumbar puncture to exclude a condition which, although unlikely to be present, if present could have had catastrophic consequences for Mr A was appropriate clinical practice. The lumbar puncture was appropriately performed and informed consent adequately taken. The investigation also found that the decision to use a lumbar puncture instead of other diagnostic procedures was in-line with guidance. Those complaints were not upheld.
The investigation found that the immediate aftercare was appropriate but although a follow-up appointment was arranged to investigate Mr A’s symptoms further, a consultation letter was not completed or shared with Mr A’s GP. This was a missed opportunity for Mr A to have trialled medication and receive a further review of his symptoms. Therefore, this complaint was upheld.
The Ombudsman recommended that the Health Board should apologise to Mr A for the failings identified and pay Mr A £350 for the missed opportunity to trial medication and receive a further review of his symptoms. The Health Board accepted the findings of the report and agreed to implement the recommendations.