Decision report 201102318

Summary
Mrs C complained that when her late husband (Mr C) was being transferred from Ninewells Hospital to his local community hospital his clinical records were not passed on and staff could not administer medication until they received them which was later in the day.

We established that Mr C's records were left in the ambulance and that responsibility for the safekeeping of the records rested with the ambulance service. Our report stated that medical records are important documents and have to be available should clinicians need to review them to obtain details of a patients medical history, medication etc. We were satisfied that in this case the delay was caused by human error. It was discovered shortly after Mr C's arrival that the records were missing and contact was made with the service. They located the records immediately and made arrangements for them to be picked up later in the day and delivered to the hospital. The hospital was content with this arrangement and stated that Mr C was not disadvantaged by the missing records and that he did not require his prescribed medication until after the records had arrived. They also explained that should Mr C have required assistance in the interim period then he would have been assessed by a clinician who would have prescribed appropriate medication if required.

Recommendations
We recommended that the service:
• review their procedures and consider whether measures such as a simple checklist could be completed by staff to ensure that medical records have been collected and delivered when a patient is transferred; and
• apologise to Mrs C for the delay in delivering Mr C's records.