Delays in diagnosis compromised patient's chances of a better outcome from surgery

What happened

Mrs P went into hospital a few days after a fall. She felt dizzy, had a bruised leg and abdominal pain, and was vomiting. Trust staff initially diagnosed swollen lymph nodes in her groin.

Mrs P continued to complain of abdominal pain. Some 11 days after she went into hospital, tests suggested she might have a bowel obstruction, and there were also signs that she was starting to experience systemic infection. Mrs P also developed an abscess at the site of her abdominal swelling.

Although staff in the Trust's acute medical unit and its critical care unit monitored Mrs P, she continued to deteriorate. A surgical review of Mrs P's CT scans, carried out more than three weeks after her admission, led to a diagnosis of a hernia that had partly obstructed her bowel. Mrs P had surgery to remove the affected part of her bowel; but she did not recover and died three weeks later.

The Trust's serious incident investigation identified that staff had misinterpreted the first CT scan images. Inadequate reviews, examinations, and handovers between medical staff had compounded this, particularly when Mrs P was moved between wards. This meant that staff did not recognise the significance of Mrs P's symptoms. The Trust was unable to say if Mrs P would have survived if it had made the correct diagnosis earlier. However, it acknowledged that she would have been in a stronger position for surgery.

What we found

The Trust misinterpreted the original scan images, and failed to review the images again when Mrs P's condition did not improve. Staff also missed opportunities to consider a diagnosis of obstructed bowel because of a hernia. We were unable to conclude that Mrs P would have survived surgery if the Trust had made the correct diagnosis earlier; however, we agreed with the Trust that the delay compromised her chances of a better outcome. This caused distress to Mrs P's Family because they will never know whether or not the outcome could have been different.

The Trust had already taken appropriate action to discuss the misinterpretation of the original images in its radiology discrepancy meeting. But its serious incident investigation report was not as robust as it could have been.

Putting it right

The Trust wrote to Mrs P's son and daughter to acknowledge the failings we found and to apologise for the distress caused. It also paid £500 compensation to them both. It developed an action plan to identify the reasons for the failings and the learning the Trust had taken from these, and to explain what it would do differently in the future.