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Health Board Apologizes for Missed Diagnosis
27 Nov
Summary
- Mesenteric ischaemia diagnosis should have been considered.
- CT scan failed to report critical gut blood vessel narrowing.
- Health board ordered to apologize and reimburse patient.
An investigation by the Scottish Public Services Ombudsman has concluded that a patient, referred to as 'C', experienced an unreasonable discharge due to a missed diagnosis. The ombudsman's findings, based on expert advice, indicated that mesenteric ischaemia should have been strongly considered given the patient's symptoms. A critical CT scan also failed to identify narrowing of the blood vessels supplying the gut, contributing to the error.
The health board has since apologized for its investigative and communication shortcomings, though it maintained that clinical decisions were appropriate. As a result, the board was directed to issue a formal apology to patient C. Furthermore, reimbursement for private treatment, including associated travel expenses to London, was mandated.
The board has accepted the ombudsman's recommendations in full. These include exercising greater care when discharging patients with persistent symptoms, considering mesenteric ischaemia in cases of unexplained weight loss, and enhancing interdisciplinary collaboration to minimize the risk of missed diagnoses. Work is reportedly underway to implement these changes.
