A&E doctor did not thoroughly assess patient's symptoms

What happened

Ms K's condition affected her vision. She went to A&E at the Trust by ambulance, because she had a headache, fever and stomach pain. Ms K said that she was also suffering from visual deterioration. The ambulance records stated that Ms K told the paramedic that her vision had deteriorated and she also informed A&E staff about this. This was not recorded in the notes, and the Trust said that the doctor was not told of this.

The A&E doctor concluded that Ms K's symptoms were probably caused by constipation and migraines. She was referred for follow up with her GP. The next day Ms K's vision deteriorated further and she contacted her neurologist, who prescribed high–dose steroids. Her vision returned to what it was before the flare up.

What we found

We partly upheld this complaint. Because of the differing accounts of events, and in the absence of any other evidence, we could not say whether Ms K mentioned visual deterioration to the A&E doctor. Her other symptoms did not indicate that medical staff should have suspected that her illness had flared up. However, clinicians should have taken further actions to investigate Ms K's condition and checked her vision because of her ongoing disease. The doctor should have reviewed the ambulance records.

These omissions meant that Ms K's assessment was not as thorough as it should have been. If the assessment had been carried out appropriately, Ms K would probably have been prescribed steroids in A&E. As she got steroids the next day, we did not think that it was likely that the delay affected her condition. However, it was clearly distressing for Ms K, and she had to get in touch with her neurologist in order to get the medication that she should have been given in A&E. This caused Ms K frustration.

Putting it right

The Trust apologised to Ms K, and agreed to explain how it will make sure that ambulance records are available to A&E staff in future.