The person who previously had a severe brain injury sought treatment at the emergency department in Umeå due to dizziness and vomiting.
Investigations were done and pointed towards a minor stroke. As there were no available care places, the person had to remain in the emergency department.
“Neurological checks are prescribed, but it is incompletely documented how the patient’s condition changed during the stay there,” writes the region in the lex Maria notification to the Inspectorate for Care and Care, Ivo.
The patient worsened and a new examination was performed. This showed that the person had suffered a major stroke. A decision was then made about intensive care. Six hours had then passed since the patient arrived at the emergency room.
“The patient’s condition and possibility of effect of treatment have deteriorated during the time in the emergency department while waiting for an examination and place of care,” the report states.
The chief physician: “Serious care injury”
The person dies a few days later.
– We are taking this seriously, it is a serious health care injury, it could possibly have been avoided that the patient died, says chief physician Bengt Andersson.
According to him, the death was not only about the lack of care places, but that an optimal assessment of the patient’s condition was not made and that it deteriorated. An action plan has been made after the death.
– It’s about getting better at noticing early signs of deterioration and better documenting information from monitoring the patient’s condition.