Trust did not monitor a biopsy properly

What happened

After an outpatient appointment, Mr C's son tried to get his father a scan and follow-up appointment much sooner than the four months given by the Trust. Mr C went to A&E, but was sent home. He got a cancellation appointment for his scan, but the follow-up appointment remained months away. Mr C returned to A&E and was admitted. He was given a liver biopsy, but bled internally from the puncture site. He died two days after the biopsy.

What we found

The outpatient appointment did not provide an adequate care plan for Mr C. He should not have been discharged from A&E. Consent for the biopsy was not properly obtained and Mr C was not properly monitored and cared for after the biopsy. Mr C was given inappropriate medication after the biopsy and the Trust lost clinical records and two crucial scan images.

The Trust's complaint handling was poor.

It was impossible to judge whether the biopsy was safe to proceed with, because of the missing records. We were unable to say if Mr C's death could have been avoided, but he was not given the best possible chance of surviving.

Putting it right

The Trust apologised, paid £500 for the poor complaint handling, and produced an action plan to prevent a recurrence.