Wrongly diagnosed mum died after hospital sent her home twice

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Health bosses have apologised after a mother was ‘unreasonably discharged’ twice from Oban’s hospital with a wrong diagnosis before dying from cancer.

In a critical report from The Scottish Public Services Ombudsman (SPSO), NHS Highland was told to say sorry to the woman’s family.

It was only when the woman returned to the emergency department at Lorn and Islands Hospital for a third time, just five days after the second discharge, that she was finally admitted and tests  carried out showed she had cancer.

The woman, called Mrs A in the report, deteriorated on the ward and died from her illness.

The complaint was raised by the woman’s son, referred to in the report as Mr C.

The watchdog report found that Mrs A was unreasonably discharged from the hospital’s emergency department on two occasions in 2016 without her symptoms being effectively managed.

‘We also found that an incorrect diagnosis had been reached during the first presentation to the emergency department, whilst the second presentation was poorly documented,’ said the SPSO report.

It was also noted that once Mrs A was admitted to the ward, there was an unreasonable delay in getting a CT scan of her chest/abdomen.

In response to the son’s complaint, the NHS Highland board apologised that inaccurate information was given to family members regarding the length of time to obtain test results.

The SPSO report also found there was a lack of discussion between nurses, doctors and the family around the possibility of discharging Mrs A home and a lack of clarity with the family about this. That aspect of Mr C’s complaint was also upheld.

Mr C was also unhappy with the time that the board took to investigate and respond to his complaint.

The SPSO recommended hospital bosses should apologise to the family for the unreasonable decisions to discharge Mrs A on two occasions, also for the incorrect diagnosis of urinary tract infection, the poor documentation of Mrs A’s second hospital attendance, the unreasonable delay obtaining a chest/ abdomen CT, the lack of local multidisciplinary discussion around the possibility of discharge and  failing to provide a reason for the complaint handling delay and a revised timescale.

It also made a number of recommendations for changes to ‘put things right in future’.

A spokesperson for NHS Highland said: ‘NHS Highland’s chief executive Iain Stewart would like to sincerely apologise to the patient’s family for the failings in care and treatment provided.  We have reviewed the findings within the report and have shared the recommendations with all the professionals involved, and have now made a significant number of improvements to current practices.’