Mr E complained that while reviewing a CT scan during a consultation on 2 May 2023, a consultant psychiatrist (“the Consultant Psychiatrist”) said that his mother had suffered Transient Ischaemic Attacks (“TIAs” – also known as “mini strokes”, they are caused by a temporary disruption in the blood supply to part of the brain). He said that his mother’s GP had not mentioned any concerns about TIAs when reviewing the CT scan report. He was concerned that, despite expressing these concerns, the Consultant Psychiatrist did not pass this information to other treating clinicians, and that this could have altered his mother’s treatment.
Mr E also complained that there was an undue delay in arranging a multi-disciplinary team meeting to review his mother’s care and that there had been a missed opportunity to identify that his mother was at risk of Deep Vein Thrombosis (“DVT” – a blood clot that develops within a deep vein in the body) when she attended for assessment of an ankle injury in May 2023. The Ombudsman decided that there was insufficient evidence of failings in relation to these complaints to warrant an investigation. However, the Ombudsman was concerned that on the balance of the available evidence it was likely that the Consultant Psychiatrist had incorrectly advised Mr E and his mother that the CT scan showed TIAs. Several opportunities were missed at the time and in response to Mr E’s complaints to provide reassurance that this was not the case.
The Health Board agreed to a number of actions to resolve the complaint. These included apologising and paying £500 to Mr E to reflect the avoidable distress caused by the uncertainty about potential TIAs. The Health Board also agreed to carry out a review of the way the CT scan was reviewed and communicated to Mr E and his mother.