Decision Report 201301162

Summary

Ms C said that, when she had eyelid surgery as a day patient, Raigmore Hospital did not provide her or her GP with a discharge letter. There was confusion about where her stitches would be removed, and who would remove them, and it was only when Ms C asked her GP about this that the fact that there was no discharge letter was picked up. Ms C also needed further clinical care for her eye before the stitches could be removed, as it had not healed correctly. For this she at first went to another hospital, before deciding to go to the accident and emergency department of Raigmore Hospital, where she had successful corrective surgery.

We took independent advice from one of our medical advisers, who examined all the evidence provided. After taking account of his advice alongside all the documentation from Ms C and the board, we upheld the complaint. The adviser said that Ms C had received appropriate treatment and advice at the hospitals, but there appeared to be a lack of clarity as to what and with whom follow-up arrangements were to be made. This was made worse when the hospital did not provide a discharge letter. We also found that the board had not fully responded to Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that in similar circumstances patients are appropriately advised on follow-up arrangements following ophthalmology treatment (treatment relating to the eye); and
• advise the Ombudsman on the steps taken to ensure that the failures in the computerised generation of the discharge letter in this case do not happen again.