Decision Report 201600147

Summary

Mr C complained on behalf of his wife (Mrs A) about the clinical treatment she received when she attended A&E at the Gilbert Bain Hospital. We took independent advice from a consultant in emergency medicine. The advice we received was that the assessment and treatment of Mrs A was reasonable and that appropriate investigations were carried out, and that Mrs A did not require hospital admission. We therefore did not uphold this complaint.

However, the advice we received said that while written notes made by the doctor caring for Mrs A were of a high standard, one thing that could have been improved was the inclusion of vital signs and we made a recommendation to the board regarding this.

Mr C also raised his concern that the doctor had failed to reasonably interpret Mrs A's chest x-ray. The board accepted that the doctor had failed to appreciate the significance of the radiographic appearance on the base of Mrs A's left lung on the x-ray. They apologised for this and explained that the issue of x-ray interpretation had been discussed with the doctor. The advice we received was that the action taken by the board was reasonable. While we upheld the complaint, given the action taken by the board we made no further recommendations.

Mr C complained that the board inappropriately discharged Mrs A when she attended the hospital, particularly as she had had to re-attend the following day. The advice we received was that Mrs A did not require hospital admission. We did not uphold the complaint.

Recommendations

We recommended that the board:

• draw the importance of including vital signs in written notes to the attention of relevant staff as part of their professional supervision.