Decision Report 201205369

Summary

Ms C complained that the board had not followed the correct diagnostic and prescribing guidelines for her condition. She said that she was wrongly diagnosed with Graves' disease (a condition in which the body produces too much thyroid hormone) at St John's Hospital, and that what she was prescribed was harmful to her. Ms C was also unhappy that other clinicians were made aware of the diagnosis of her condition as being non-physical rather than physical, and said this had an adverse effect on her care and treatment. This diagnosis was retracted after Ms C complained, but she was unhappy that there was reference in her medical records to her complaint. She was also unhappy with the way her complaint was handled and said that the board had failed to carry out action they had agreed.

We took independent advice from one of our medical advisers, who is a consultant in endocrinology (a branch of medicine dealing with hormones). The adviser found no evidence that the board failed to follow the correct diagnostic and prescribing guidelines for Ms C's condition. He did say, however, that her disease was mild and was not the cause of her symptoms, and that the board should have looked more actively for other causes for Ms C's ill health. We found that Ms C had received attentive care and that the conventional guidelines (British Thyroid Association guidelines) were followed. We found no evidence that diagnosis of her condition as non-physical rather than physical had an adverse effect on treatment.

We were also satisfied that the board had responded to Ms C's concerns and had met with her to try to address her concerns. They had clearly explained that because the issues were about events from a number of years ago they were not going to investigate her complaint on a point by point basis. We were also satisfied that the board had done what they said they would, although we were concerned about the reference to the complaint in Ms C's medical records. Although we did not uphold her complaints, we made three recommendations to try to ensure good practice in future.

Recommendations

We recommended that the board:

• ensure that the medical advice we received in relation to this complaint is brought to the attention of the relevant clinicians;
• remind all staff that information about a patient's complaint should not be contained within medical records; and
• ensure that, in this case, the procedure for dealing with disagreements about entries on medical records has been followed.