Failings in Mr B's care led to the misdiagnosis of a rare acute cardiac condition. However, it is likely his condition had already progressed too far by the time he was first seen in A&E and so his death could not have been avoided.
What happened
Mr B went to the Trust's A&E department with abdominal pain on three occasions over just a few days. The first time, he was diagnosed with a suspected kidney stone that had passed and staff discharged him. Mr B's GP referred him to A&E two days later. Staff in A&E then diagnosed an underactive thyroid and obstructive sleep apnoea (when breathing stops for short spells during sleep), and Mr B was again discharged.
Mr B's GP referred him to A&E a third time, and he was admitted to hospital for investigation. After tests, doctors made the correct diagnosis of aortic dissection (a tear in the wall of the aortic artery) and Mr B had emergency surgery. He continued to deteriorate, and further surgery found the blood supply to Mr B's bowel had been affected by the dissection. Unfortunately, Mr B did not recover after the surgery and he died within a few days.
What we found
We partly upheld this complaint. When Mr B first went to A&E, staff assessed, examined and reviewed him in the correct timescales. They arranged the right observations, tests and scans on the basis of his symptoms and the suspected diagnosis. Although the first diagnosis was incorrect, it was a reasonable working diagnosis, given the information doctors had at the time.
There were failings by the Trust during Mr B's second visit to A&E. The doctors did not link his symptoms, including low blood pressure, and this meant that Mr B was discharged instead of being sent to the medical and cardiology teams for further investigation.
During his third visit to A&E, Mr B's care was carried out by the A&E teams. This is contrary to an agreement by the College of Emergency Medicine that patients returning to A&E within 72 hours should be seen by a senior doctor. That said, the A&E team made a reasonable diagnosis, and Mr B was admitted for investigations that led to the correct diagnosis of aortic dissection.
Mr B and his family were distressed by his repeated visits to A&E. However, it was more likely than not that by the time Mr B first went to A&E, the aortic dissection had progressed so far that it had already affected the blood supply to his bowels. We were not able to say that Mr B's death could have been prevented, even if the correct diagnosis had been made earlier.
Putting it right
As the Trust had already completed a serious incident investigation report and action plan, we asked it to update the action plan to address the failings we had identified. It agreed to do so and to share the updated plan with Mrs B, the Care Quality Commission and Monitor.
King's College Hospital NHS Foundation Trust
Greater London
Did not apologise properly or do enough to put things right
Did not take sufficient steps to improve service
Recommendation to learn lessons or draw up an action plan