Failings in A&E caused confusion about diagnosis

What happened

Mrs W had chronic lymphocytic leukaemia and was on antibiotics for a urinary tract infection. She felt very unwell and went to A&E. Blood test results were abnormal and the A&E doctor discussed next steps with the on-call medical specialist before discharging Mrs W with increased antibiotics and advice for her GP to repeat the blood tests in a week.

From what she was told in A&E, Mrs W believed she had hepatitis A and her GP accepted this information because he had not had any information about her A&E attendance when she visited a week later. After further tests and investigations, Mrs W was diagnosed with metastatic bone cancer three weeks later. No diagnosis was documented in the A&E record.

Mr and Mrs W complained to the Trust about the misdiagnosis of hepatitis A and that staff did not document it or report it to her GP. They also complained that the Trust did not do enough to investigate and treat her symptoms. They said the failings in care delayed the eventual diagnosis and Mrs W's pain worsened during this period.

The Trust acknowledged and apologised for not providing pain relief. It also acknowledged that the information given to the GP should have been clearer. It outlined steps taken to address these issues. It apologised if Mrs W had been given misleading clinical information, but there was nothing in the records about hepatitis A. It said it was not uncommon to discharge patients without a diagnosis if none could be found.

What we found

Overall, the assessment and the decision to discharge Mrs W back to the GP (as documented in the records) were reasonable. However, the Trust should have carried out a urine test and should not have increased the antibiotics without a urine test. These failings did not affect the outcome in this case.

We did not find, on the available evidence, that there were failings in diagnosis and documentation in relation to hepatitis. However, failings in communication resulted in Mr and Mrs W's belief that the Trust had diagnosed hepatitis. This affected subsequent consultations with the GP and may have resulted in a small delay in carrying out further tests.

The A&E doctor should have made a discharge diagnosis.

The system for reporting A&E attendances to GPs was not robust, but we were unable to conclude that the Trust was responsible for Mrs W's GP not receiving the report.

Putting it right

The Trust implemented a new system that allowed typed summaries to be sent to GPs electronically. It also changed the way A&E staff prepared GP reports, to increase clarity. These steps were implemented before we completed our investigation. This systemic action will reduce the likelihood of a recurrence.

The Trust took appropriate steps to address the matter of pain relief with staff and apologised that Mrs W was not given pain relief. This was reasonable and we did not recommend any further action.

The Trust will write to Mr W to acknowledge the failing in communication and that a discharge diagnosis should have been made in this case. The Trust will take our feedback that medical staff should be encouraged to make discharge diagnoses as a learning point.