Patient not referred to multidisciplinary team

What happened

In spring 2012, Mr V's GP referred him to the Trust because he had been vomiting for two weeks and had unexplained weight loss. Doctors carried out a number of investigations but were unable to diagnose what was wrong. In autumn 2012, Mr V was admitted to the Trust with a severe infection. His condition rapidly deteriorated and he died the following day.

What we found

The Trust conducted appropriate and timely investigations, and referred Mr V, where necessary, to the vascular department. A vascular surgeon made appropriate arrangements to review Mr V following his admission in autumn 2012.

However, whilst under the care of the vascular department, a junior doctor failed to refer Mr V's care to the multidisciplinary team. We could not say, even on the balance of probabilities, that Mr V's care would have differed had he been referred to the multidisciplinary team, but knowing that her husband was not referred when he should have been was upsetting to Mrs V.

The Trust appropriately responded to Mrs V's complaint.

Putting it right

The Trust had already acknowledged the failing identified in this case, and we recommended that it apologise to Mrs V for the service failure.

It assured Mrs V that the junior doctor involved had learnt from this case, and told her how it would ensure doctors did not make similar mistakes.