Failure to properly assess patient's condition

What happened

Mrs Y had been suffering with breathlessness and difficulty breathing and her GP had been investigating whether her asthma was the cause. After a change in her asthma drugs did not have any effect, Mrs Y was referred for an urgent hospital admission at the Royal Hampshire County Hospital (the Hampshire Hospital ‑ managed by Hampshire Trust).

Staff carried out tests to exclude the possibility of a pulmonary embolism. The tests included a chest X‑ray, a test to measure the electrical activity of the heart (an ECG) and a full blood count but none of these showed anything abnormal. Mrs Y was discharged the same day. Mrs Y's GP then referred her to the Hampshire Hospital's chest clinic.

In the following months Mrs Y received care from both the Hampshire Trust and the University of Southampton Trust, but consultants were unable to determine the cause of her illness until it was too late and Mrs Y died.

What we found

The care given by the GP practice was in line with established good practice. The care provided by both Trusts was also in line with established good practice. We did not uphold these aspects of the complaint.

However, we found a number of failings in Mrs Y's initial appointment at the Hampshire Hospital. The clinical history lacked detail about her asthma, and there was no information about whether her symptoms changed throughout the day; whether she experienced night‑time symptoms; the type of medication she was on or whether she had previously had severe asthma attacks. In addition, the junior doctor did not measure Mrs Y's peak flow which would have been central to an assessment of her condition and in line with asthma guidelines.

Although the oxygen level in Mrs Y's blood was reduced, the junior doctor did not measure her blood gases, which was also not in line with national guidance. It was not safe to assume asthma and anxiety were the causes of Mrs Y's symptoms, and the junior doctor should have discussed her case with a senior doctor, but he did not do this.

All these mistakes amounted to service failure. An opportunity was missed to refer Mrs Y for appropriate review sooner, although we concluded that it was more likely than not that she would still have died. We also found an injustice to her family, as they will never know if that would have made a difference.

Putting it right

The Hampshire Trust apologised to Mrs Y's mother Mrs D, who brought the complaint to us, and paid her £1,000. It agreed to prepare an action plan to show what it had done to stop these failings happening again.