Decision Report 201403399

Summary

Mr C complained about the medication he was prescribed at Dumfries and Galloway Royal Infirmary. He said the side effects were not explained to him properly and that his medication had caused him to suffer problems with his lungs.

As part of our investigation, we took independent medical advice from one of our advisers. He explained that not discussing the medication’s side effects would have been unreasonable and that such discussions should ideally be noted in the medical records. Our adviser was unable to determine the extent of any such discussions from Mr C’s medical records and, although he accepted it was possible that it may have caused Mr C’s subsequent health problems, he said it was a low probability. However, he said the actual decision to have prescribed the medication was not, of itself, unreasonable.

In light of the advice we received, we could not absolutely say Mr C’s medication caused his health problems or the decision to have prescribed it was unreasonable and so we did not uphold his complaint. We did, however, have reservations about the extent of the discussions about its possible side effects and the extent of the assessment that was done for Mr C and so we made three recommendations.

Recommendations

We recommended that the board:

• remind clinical staff of the importance of accurate note keeping;
• remind staff to carry out and follow up on appropriate physical examinations for lung disease (particularly where symptoms such as lung crackles have been identified); and
• remind clinical staff of this medication’s side effects and the need to explain them to patients, particularly in light of patients’ presenting symptoms.