Decision report 201103900

Summary

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems.

Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol.

Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition.

Our adviser found that the lack of information in the notes taken at the time did not give a full picture of Mrs C's condition on the night in question. However, he was of the view that with the information now known - that Mrs C had concussion - the management of her condition would have been the same even had the concussion been diagnosed at the time. Mrs C was discharged with a small amount of medication and with advice to return to A&E if her condition worsened. The adviser said that this would have been appropriate. He was also of the view that Mrs C's ongoing problems would probably have occurred even had the concussion been diagnosed at the time. We did, however, uphold Mrs C's complaint because no valid reason was recorded in the notes for the GP not having conducted a full assessment and examination at the time.

Recommendations

We recommended that the board:

• apologise for the failings identified during our investigation; and
• review a sample of notes to establish the quality of record-keeping of the staff involved.