The Royal Infirmary of Edinburgh sent a sick man home without realising he had advanced prostate cancer and a fractured hip.
The Scottish Public Services Ombudsman (SPSO) has rapped NHS Lothian after the patient was sent home from the hospital without the required medical examination taking place.
The man, named by the SPSO as Mr C, attended A&E at the hospital after experiencing pain in his back and leg.
He was assessed by an on-call orthopaedic doctor and an x-ray was performed – before he was admitted to an orthopaedic ward and discharged four days later.
An SPSO spokesperson said: “Weeks later, Mr C returned to hospital and a hip x-ray was performed.
“Investigations over the following days identified that Mr C had a pathological hip fracture and advanced prostate cancer.
“Mr C underwent a hip replacement procedure and was referred to the uro-oncology service.”
Investigations were 'inadequate'
Mr C complained to the SPSO about the delay in accurately diagnosing his condition and that he was unreasonably discharged from hospital during the first admission.
The spokesperson added: “We took independent advice from a consultant orthopaedic surgeon.
“We were critical that the board were unable to provide the in-patient orthopaedic notes for Mr C’s first admission, other than the summary of ward rounds.
“We found that the investigations performed following Mr C’s initial presentation to the board were inadequate.
“We found that a hip examination and hip x-ray should have been performed given the examination findings.
“We considered it was likely that the failings in this case led to a delay for hip replacement surgery, during which time Mr C continued to suffer pain from the condition.
“We upheld this aspect of Mr C’s complaint.”
The SPSO said that due to “the absence of the orthopaedic records” relating to the first admission to hospital, “the board were unable to demonstrate that Mr C had been safely discharged”.
The SPSO concluded that the decision to discharge Mr C was unreasonable and upheld the complaint.
The ombudsman ordered NHS Lothian to apologise to Mr C for the failure to examine and investigate his hip, and for poor record-keeping.
The SPSO formally reminded NHS Lothian that patients with thigh pain and an inability to weight bear should have a hip examination performed.
An individual who is unable to do an active straight leg raise and is unable to bear weight should have a hip x-ray performed.
The organisation was also told to ensure clinical records are appropriately managed.
A public apology
Professor Alex McMahon, executive director of nursing, midwifery and allied healthcare professionals at NHS Lothian, said: “I would like to take this opportunity to apologise again and publicly to Mr C.
“We fully accept the ombudsman recommendations and have completed the actions that were identified by the Scottish Public Services Ombudsman, this includes ensuring the management of clinical records is appropriate, and making sure relevant examinations and x-rays are carried out in a timely manner, particularly when pain is preventing a person’s mobility.
“NHS Lothian takes all complaints very seriously and has learned lessons from this issue.”
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