Tayside doctors failed to diagnose that an emergency patient had suffered a stroke, an inquiry has found.
Instead they thought she had a migraine and sent her home. It was only when her GP referred her urgently to hospital that her condition was recognised.
The Scottish Public Services Ombudsman has now ruled she did not receive proper treatment and has told NHS Tayside to change its procedures.
The woman, named in the ombudsman’s report as Mrs C, attended a hospital accident and emergency department twice.
It is not stated in the report if the incident took place at Ninewells Hospital in Dundee or at Perth Royal Infirmary.
An NHS Tayside spokeswoman declined to identify the hospital, saying: “The ombudsman’s reports are always anonymised due to patient confidentiality, therefore we cannot release any further details.”
The patient’s husband told the ombudsman that she had been displaying symptoms of stroke on both occasions. The second time she was discharged, even though she was unable to speak without slurring.
The inquiry found that on her second visit to A&E it had been unreasonable for Mrs C to have been diagnosed as suffering from migraine.
There was no record of either a FAST (face, arm, speech, time of event) assessment or of a ROSIER (record of stroke in emergency room) review to check if Mrs C had suffered a stroke.
The ombudsman did not uphold a complaint that doctors had ignored the woman’s slurred speech as her medical notes clearly detailed the symptoms.
It recommended that NHS Tayside apologise to the woman and her husband for the failings in her care.
Managers were told they should review the processes governing referral to the on-call neurology team when a patient has symptoms consistent with hemiplegic migraine, which causes temporary weakness on one side of the body.
The NHS Tayside spokeswoman said: “The board has accepted the recommendations in the report and will act on them accordingly.”