Decision Report 201704830

Summary

Mrs C complained about the care and treatment she and her baby received during and after the birth at the Royal Alexandra Hospital (RAH) and the Royal Hospital for Children (RHC). Mrs C was concerned that the baby was not admitted to the RHC when they attended A&E with concerns about the baby's eyes. Mrs C also had concerns about her care as she had to be readmitted to RAH for a procedure and later again for treatment of sepsis (blood infection).

We took independent advice from a midwife and consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the in-patient care and treatment Mrs C and the baby received from both midwifery and medical staff was of a reasonable and appropriate standard. We did not uphold the complaint about the baby's care and treatment.

However, we upheld the complaint about Mrs C's care and treatment on the basis that there was a failure in communication with Mrs C about her discharge medication and the record-keeping associated with this. We found that there was no evidence in the medical records to confirm that Mrs C was given information about the safety and dose instructions of the painkillers (paracetamol and ibuprofen) she was prescribed. We considered that this was not appropriate and could have resulted in serious harm in the event of an inadvertent overdose.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failing in communication about discharge medication and record-keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

What we said should change to put things right in future:

• The recommended/maximum daily dose and frequency of both paracetamol and ibuprofen should be documented in the medication section of the discharge letter. Staff discharging patients should document that the recommended/maximum daily dose and frequency of medication has been clearly explained to the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.