Decision Report 201605471

Summary

Mrs C complained to the board about the care and treatment she received when she was admitted for elective hip replacement surgery at Dumfries and Galloway Royal Infirmary.

Mrs C recalled feeling pain before the procedure finished, known as breakthrough pain, and complained to us about the level of anaesthesia she was given during surgery. We took independent advice from an anaesthetic adviser, who was satisfied that that both the type and dose of anaesthetic and sedative drugs used were appropriate in this case. They did not find a record of breakthrough pain in the notes, and they could not confirm what action might have been taken in response to this. As the evidence available was not conclusive about the reported episode of breakthrough pain, we could not conclude that there was a failure to document pain and the use of top-up anaesthetic. We did not uphold this complaint.

Mrs C also raised concerns that staff did not maintain reasonable records following the operation, and that the records failed to reflect that she was in pain. We received independent advice from an adviser in general medicine and a nursing adviser. The general medicine adviser was satisfied that the frequency and detail of the entries in the records by medical staff was in accordance with normal practice, and they considered that the record-keeping was reasonable. The nursing adviser found that the nursing records had been maintained to a reasonable standard and were in accordance with the professional code of practice. We concluded that the record-keeping was reasonable and we did not uphold this complaint.