Decision Report 201708352

Summary

Mr C complained on behalf of his wife (Mrs A) about a delay in carrying out a CT scan (a scan that creates detailed images of the inside of the body). Mrs A was taken to A&E at Dumfries and Galloway Royal Infirmary and following a CT scan, was diagnosed with having suffered a stroke. Mr C felt that the scan should have been carried out sooner.

We took independent advice from a medical adviser. We found that records of Mrs A's history and examination were inadequate. This meant that we were unable to conclude what Mrs A's condition was at the time of her assessment in A&E and, therefore, if the CT scan was completed within a reasonable time frame. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to document Mrs A's history and examination in line with the relevant guidance. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of relevant standards of documentation in terms of timed entries in clinical notes, documentation of relevant history and examination appropriate to the presenting complaint and documentation and timing of changes in clinical condition, clinical findings and action plan.