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Case ref:201300973
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Date:November 2014
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained that when she was admitted to Aberdeen Royal Infirmary staff did not take account of her specific condition when treating her, did not appropriately access her medical notes, and did not keep accurate and secure test results.
Mrs C suffers from a chronic condition which can cause an imbalance in blood chemistry, particularly sodium and potassium. She had also just had a bout of gastroenteritis (vomiting and diarrhoea) and had been prescribed dioralyte (a medication used to replace fluids and regulate blood chemistry after diarrhoea) by a locum (temporary) GP. When she saw her own GP after she had been ill for six days, she was referred to the hospital, and was admitted. Mrs C was given a saline drip (to prevent dehydration) and kept in overnight then discharged the following day. Since then Mrs C has suffered ongoing symptoms of tiredness, weakness and an inability to tolerate any foods containing sodium or potassium, which she attributes to the treatment she received.
Mrs C said that when she tried to tell medical staff that the combination of treatment she had received from the locum GP and the hospital would have a negative effect on her, they dismissed her views and began writing in the medical records of another patient with a similar surname to hers. Mrs C also said that a person wearing a white coat told her that they had amended her blood test results to read as normal to prevent her getting treatment.
Our investigation included taking independent advice from one of our medical advisers, who said that the medical records showed that Mrs C's treatment was reasonable, appropriate and would have been very unlikely to have caused the symptoms she described. We were also satisfied that there was no evidence of any gaps, inaccuracies or tampering with Mrs C's medical records or blood test results. We asked the board what they had done to investigate Mrs C's concerns about her medical records and blood test results, and were satisfied that they had carried out extensive and appropriate investigations and found no evidence to support her concerns.