Mr A complained about the care and treatment afforded to his late wife, Mrs A. The investigation considered whether Mrs A’s discharge from the Endoscopy unit, following an endoscopic retrograde cholangiopancreatography (“ERCP” – a technique used to examine the pancreas and bile ducts) and the management of Mrs A’s condition following her attendance at the Emergency Department (“the ED”) were clinically appropriate.
The investigation found that whilst the decision to discharge Mrs A was clinically appropriate, the written discharge advice regarding who to contact should symptoms of pancreatitis (a condition where the pancreas becomes inflamed over a short period of time) develop, was not of an acceptable standard. The information given was confusing and led to advice being sought from services that could not assist. There were delays in ED triage, medical assessment, administering pain relief, commencing intravenous fluids and carrying out blood tests. This culminated in an overall delay in the diagnosis of acute pancreatitis. This was an injustice to both Mrs A and her family. Both aspects of the complaint were upheld.
The Health Board agreed to provide Mr A with a written apology and to review this case to identify any points of learning which can be applied in future care. It also agreed to consider introducing a policy regarding the management of acute pancreatitis which should include the issue regarding re-presentations of patients after ERCP and streaming of them to either a Medical or Surgical team depending on local practice.