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Case ref:201402731
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Date:February 2015
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Miss C attended the A&E department at Hairmyres Hospital with abdominal (stomach) pain. After examination in A&E, she was transferred to one of the wards. She complained about her treatment in both A&E and on the ward, in particular that a doctor wrongly decided she was an abuser of alcohol which had an impact on the treatment she was given.
We took independent advice from one of our medical advisers. Our investigation found that the doctor had formed the conclusion about the alcohol use from a 13-year-old entry in Miss C's medical records, which referred to one episode of alcohol abuse at that time. We did not consider it was appropriate to make the assumption he made from that entry and concluded the doctor should have made more of an effort to find out the current facts. As we otherwise found Miss C's care and treatment to be appropriate, we did not uphold the complaint but we made two recommendations.
Recommendations
We recommended that the board:
- add a note to Miss C's medical records to show the context in which they made their remarks about previous alcohol excess and about a treatment plan; and
- ensure that the doctor discusses the complaint with his education supervisor as part of his training record.