Decision report 201100638

Summary
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection.

We found that Mr C had been monitored appropriately following his admission to the hospital. The SEWS (the Scottish Early Warning Score) charts had been completed regularly and appropriately throughout his admission. There was no evidence to suggest that the monitoring, assessment and management of his pain was not reasonable.

Although Mr C complained that he was not provided with his regular prescribed medication until the day after he was admitted, the drug administration record showed that he had self-administered some of his medication on the day of his admission. We found that staff clearly failed to provide him with other medication that he needed, but had not taken to the hospital. We upheld Mr C's complaint about this. However, we did not make any recommendations, as the board had already apologised to Mr C and were taking action to reduce the likelihood of similar problems recurring.

Mr C also complained that the board did not provide him with oral antibiotics for 26 hours after he was taken off an intravenous antibiotic drip, despite his repeated requests and complaints. We upheld this complaint, as the records were not clear on the matter. It was not possible for us to say categorically whether there was a delay in providing him with oral antibiotics or whether the original intention was that the antibiotics should be stopped.
We did not consider that Mr C was asked inappropriate questions in A&E or that the questions were unnecessarily duplicated when he was transferred to a ward. Mr C also complained that the records of his stay in the hospital had been fabricated. We found no evidence of this. In addition, we found that the board's handling of his complaint was satisfactory.

Recommendation
We recommended that the board:
• remind the medical staff involved in Mr C's care and treatment of the need to keep clear, accurate and legible records, which report the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigations or treatment.