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Case ref:201600680
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Date:March 2017
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Body:Lothian NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:record keeping
Summary
Following a private hernia operation, Mr C was referred to the Royal Infirmary of Edinburgh for pain management. Mr C had various appointments with a consultant over a nine-month period, and required further surgery. Mr C later complained that the consultant had failed to complete appropriate clinical records which fully explained why he needed further treatment. Mr C told us the lack of records had caused him a problem when he went to get insurance when travelling abroad for work.
We took independent clinical advice. We found Mr C's medical records were of the standard, and in the detail, expected of NHS clinical records. We were satisfied the reason Mr C required surgery was appropriately documented. We did not uphold Mr C's complaint.