By Grant Smith

NINEWELLS HOSPITAL in Dundee has been told to carry out an urgent review of practices at its accident and emergency department after staff three times failed to assess properly a 65-year-old woman, and wrongly sent her home.

She was brought back a fourth time, having suffered a heart attack, but died at the coronary care unit.

The woman’s daughter, unsatisfied with an explanation from NHS Tayside, asked the Scottish public services ombudsman to look into the case.

An inquiry found the patient, known only as Mrs A, had a history of pulmonary disease.

She first attended A&E on March 26, 2004, with back, hip and leg pain and was sent home with a diagnosis—later discounted—of a small fracture.

She came back the next day in increased pain and having difficulty bearing her weight. After a fresh diagnosis of sciatica, she was given a morphine injection and again discharged.

On April 13 an ambulance brought the woman in. She had breathing problems. A doctor thought her pulmonary condition had worsened and sent her home with a course of steroids.

The next day she was again brought in by ambulance. She was suffering from chest tightness and extreme difficulty in breathing. A day later she died.

Her daughter thought the outcome might have been different if her mother’s chest problem had been addressed on the 13th.

The ombudsman’s nursing adviser examined the notes taken by A&E staff. A discharge profile form for March 26 had been “minimally completed” with an illegible signature.

The records for March 27 were also “limited” and, although the treatment Mrs A was given appeared to have been reasonable, there was no written evidence of a full and relevant assessment having been carried out.

When Mrs A came back the third time, a test was carried out to see how much oxygen was getting into her blood. However, the notes did not say if this was done when she was breathing normal air or using an oxygen mask.

The nursing adviser said Mrs A had been discharged less an hour after arriving at Ninewells, which was “somewhat hasty.”

It was also concerning that regular monitoring of her pulse, blood pressure, respiratory rate and oxygen level did not appear to have been carried out.

The ombudsman also asked a medical adviser to review the case notes.

This inquiry found that, while the medical assessments on March 26 and 27 seemed reasonable, the lack of proper assessment for discharge was “very poor practice” and the documents used in this process had been “neglected.”

On April 13 Mrs A came back with shortness of breath, rapid respiration, sweating and cyanosis—a blue tinge to the skin caused by a lack of oxygen. She underwent an electrocardiogram test.

Some of the symptoms were consistent with her long-standing pulmonary disease, but the medical adviser believed it was unreasonable to discharge her without excluding cardiac pain.

The ombudsman’s report said the medical adviser “told me that the level of assessment, observation and investigation as recorded on April 13 fell short of what would be expected.

“Mrs A clearly had a myocardial event within 24 hours, which caused her death. Although this could not have been predicted by the documented findings on April 13, her illness at that time almost certainly contributed to the events of the subsequent 24 hours.”

NHS Tayside’s acute chest pain protocol was examined. It made it clear Mrs A should have had a second electrocardiogram and appropriate blood tests.

“The reason why these were not done has not been uncovered,” the ombudsman said.

The medical adviser said Mrs A was not managed according to the protocol or reviewed by senior medical staff.

The documentation in her case was inadequate to provide reassurance that full consideration had been given to her cardiac status before her discharge on April 13.

The ombudsman said, “I have concluded there were major failings in the nursing component of the department’s documentation, which failed to show evidence that full nursing assessments had been carried out.

“I am also concerned that staff did not undertake a thorough investigation to exclude a diagnosis that acute heart problems were the cause of Mrs A’s symptoms and that she was discharged home without this being actioned.

“In view of the failures in documentation relating to all three attendances and the failure to fully investigate Mrs A’s symptoms on April 13, I have concluded that, on the balance of probabilities, Mrs A was inadequately assessed when she presented at the department and that she was discharged without full consideration being taken of her home circumstances.”

But it was not possible to say the “sad final outcome” would have been different with proper assessments.

The ombudsman recommended NHS Tayside audit all the departmental nursing documentation and review the chest pain protocol.

NHS Tayside accepted the recommendations and has been asked to keep the ombudsman informed of progress.