AYRSHIRE'S health board has been told to apologise to an elderly patient after a fractured neck was misdiagnosed.
A report from the Scottish Public Services Ombudsman (SPSO) revealed that the patient attended an Ayrshire emergency department after a fall at home and was treated with painkillers for a pain in the neck.
They were admitted to the ward for further monitoring of their fast and irregular heartbeat.
The SPSO said that the patient was reviewed the next morning and discharged that day.
But they returned to hospital later that day after another fall.
According to the report, they were admitted to the ward where they were diagnosed with a fracture of a bone in their neck - from the original accident.
When the family of the patient complained to NHS Ayrshire and Arran, they were told that the board did not identify any failings. But they did admit the communication of their diagnosis and discharge "could have been better".
The family then complained to the ombudsman, who this week ordered the health board to apologise to the patient - known as 'A' in the report - and review their practices.
The report from the SPSO said: "In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward.
"However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function.
"We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of the complaint.
"In relation to A's second admission, we found that A’s neurological examination did not include a cervical spine assessment.
"The board acknowledged in their correspondence with our office that the care provided at this time was not to an acceptable standard.
"Therefore, we determined that the care provided in the emergency department was unreasonable."
The ombudsman ruled that the health board should apologise to the patient and their family.
They added: "Clinical staff should be familiar with relevant NICE guidelines on the management of suspected cervical fractures. Relevant departments concerned should review their practices regarding the assessment of pain and investigation of potential head/neck injury.
"Patients should only be discharged following appropriate review and assessment of all clinical factors relevant to the decision to discharge a patient from hospital.
"We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set."
NHS Ayrshire & Arran's executive nurse director Jennifer Wilson said: "We apologise that we did not meet the high standards of care we aim to provide at NHS Ayrshire & Arran.
"The board fully accepts the recommendations in the Scottish Public Services Ombudsman (SPSO) report.
"We have issued a formal apology to the family of patient A, and are working through the recommendations highlighted in the Scottish Public Services Ombudsman (SPSO) report.
"We will ensure that the lessons learned from the report are shared throughout the organisation."
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