-
Case ref:201502760
-
Date:January 2016
-
Body:Lothian NHS Board
-
Sector:Health
-
Outcome:Upheld, recommendations
-
Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the aftercare provided to her father (Mr A) at the Royal Infirmary of Edinburgh following hip replacement surgery. She said a student nurse had removed some stitches while cleaning his wound and, on discharge from hospital, Mr A was not fitted with compression stockings. Mr A's leg then began to swell. As there was a possibility he would suffer a blood clot, he had to reattend hospital. Mrs C was unhappy the board had maintained that the stockings were fitted on discharge.
The board apologised that the stitches were removed in error. They said that the prompt action of arranging a medical review resolved the mistake. They also said that the records showed evidence that the stockings were fitted on discharge.
We took independent advice from a nursing adviser. The adviser said that the action taken after the accidental removal of the stitches was appropriate. However, the medical records contained confusing and contradictory information about whether the compression stockings were fitted on discharge. Stockings had been fitted immediately following surgery but, as Mr A's heels were becoming marked, their use had to be reassessed before he was discharged. However, there was no evidence that they were reassessed. We upheld the complaint.
Recommendations
We recommended that the board:
- apologise to Mr A for the failure to keep clear and accurate hospital records; and
- remind the staff involved of the importance of keeping clear and accurate hospital records.