Decision Report 201403700

  • Case ref:
    201403700
  • Date:
    July 2015
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about her discharge from a private hospital, which she had been admitted to for NHS-funded hip replacement surgery. She felt she was not fit to be sent home as she had severe diarrhoea, which she blamed on being given too many laxatives on the day of discharge. She needed to be admitted to hospital a few days later, where she remained for over four weeks. The board said that she had not been given any laxatives on the day of discharge and they considered that she had been fit to go home.

We took independent advice from one of our medical advisers and he said there was no evidence of Mrs C having been given laxatives on the day of her discharge. However, he did not consider that her bowel symptoms had been properly investigated and treated prior to sending her home. He said there seemed to have been undue focus placed on meeting the planned discharge date rather than ensuring Mrs C was fit to go home. As such, Mrs C required prompt readmission to have her bowel symptoms addressed. The adviser also noted that the records from Mrs C's admission lacked the detail that could reasonably have been expected. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

  • confirm that the identified failings will be discussed at the consultant's annual appraisal;
  • remind staff of the importance of comprehensive record-keeping; and
  • apologise to Mrs C for the identified failings in her care.

Updated: March 13, 2018