Abdominal pain and errors in the Emergency Department (A+E)

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5-10% of patients in Emergency Departments have abdominal pain. Unfortunately, many are misdiagnosed. The Royal College of Emergency Medicine highlighted this when it put out a safety alert for doctors in 2016.  It warned that a number of serious conditions were being missed, leading to patients dying. This is a particular risk for older patients who are 6 to 8 times more likely to die than younger ones.

Abdominal pain

A number of quite different conditions can cause abdominal pain and it is not always easy tell them apart. Pain is in the abdomen may be caused by problems elsewhere – for instance, the heart, lungs, stomach, gallbladder, kidneys, liver or testicles. They may also be conditions which require surgical care (ie operations) or medical care (including prescribing medicine).

What gets missed?

Conditions that are missed include:

  • Ruptured aortic aneurysm. This is a very serious condition when there is a weakness in the main blood vessel from the heart. The weak section balloons out and may eventually burst. This is an emergency and patients need an urgent operation. Short delays can prove fatal.
  • Bowel ischaemia. This is where blood supply to the bowel is disrupted and a section of the dies. It may be caused by disease in the blood vessels, a blood clot, a blockage of the bowel (obstruction) or infection. The contents of the bowel leak into the abdomen and patients can develop peritonitis.
  • Infection can lead to sepsis. This is where the body reacts to infection and vital organs start to shut down. Pain in the abdomen can be one sign of sepsis.
  • This is not the most common cause of abdominal pain but it is the most common to need surgery. One of the classic signs is rebound pain – pain not only when pressing on the abdomen but when releasing that pressure. The condition is seen most in children and young adults but can present in older people.
  • This is a low level of sodium in the blood. It can cause nausea and vomiting, spasms and cramps. Left untreated it can lead to seizures, brain injury, coma and even death. The condition is more common in older adults with other medical problems.

What goes wrong?

A number of things can go wrong.

  • There are so many possible causes of abdominal pain that doctors may focus on the wrong condition, particularly if they are inexperienced. Pain is often ‘non-specific’. In other words, it is not necessarily specific to one condition. Different conditions may cause the same sort of pain. People over the age of 70 – for whom abdominal pain suggests higher risks – should not be discharged without being seen by a senior doctor (ST4 or above).
  • Communication failures. The right information may not be passed on from ambulance crews or between different clinicians. Doctors or nurses starting a new shift will not have seen what a patient was like during the previous shift. They are reliant on good notes in the records. Communication failures may stop staff from recognising that a patient is getting worse.
  • Failing to use NEWS systems correctly. NEWS stands for ‘National Early Warning Score’. It is a scoring system based on a patient’s observations (such as blood pressure, heart rate, breathing rate, temperature and blood-oxygen levels). It is designed to alert clinicians to when patients deteriorate. Failing to take observations, record them correctly and use the scoring system can mean no one notices that a patient is getting sicker.
  • Failing to do the right investigations. Certain investigations are important for certain conditions. For instance, patients who may have a ruptured aortic aneurysm should have a CT scan. There may be times when the CT scanner is not available. Or doctors may be falsely reassured by blood tests into thinking nothing more needs to be done. But with rapidly developing conditions such as appendicitis or bowel ischaemic, blood results may not yet seem very abnormal.
  • Dismissing symptoms that cannot easily be explained. People can present in unusual ways. Not everyone has the classic symptoms of a condition. There is a danger of failing to recognise the significance of a particular symptoms and ignoring it because it doesn’t fit the classic picture of a condition.
  • Not listening to patients, their carers or other staff. In particular, doctors sometimes fail to realise the significance of people coming back to the Emergency Department having been discharged before.
  • Pressure to discharge patients. NHS Emergency Departments used to have a target of admitting, transferring or discharging 95% of patients within 4 hours. That has now changed to 76%. In the pressure to discharge patients, serious conditions may be overlooked.
  • NHS Resolution manages negligence claims against NHS hospitals. It has recognised in its annual report that some of these are common themes giving rise to claims.

We are here to help

Our lawyers at Enable Law have successfully pursued claims for people who abdominal pain has been misdiagnosed in Emergency Departments.

 

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