Decision Report 201800796

Summary

Mrs C complained to us that nursing staff failed to document her concerns appropriately at a pre-operative assessment before she had a wisdom tooth surgically removed. She said that she told them that she was extremely anxious and that it was agreed that she would be taken first on the list for surgery. However, when she attended hospital to have the surgery, she was not first on the list and this made her extremely distressed.

We took independent advice from a nursing adviser. We found that there had been a failure to document the concerns Mrs C raised at the pre-operative assessment and that this had made her extremely anxious on the day of the surgery. We upheld this complaint.

Mrs C also complained that nursing staff had been rude and dismissive about her concerns when she attended the hospital for the surgery. We did not find any evidence to support this aspect of her complaint and we did not uphold the complaint.

Mrs C complained that she had not been given adequate pain relief after the surgery. We found that the board had not documented Mrs C's request for stronger pain relief at the pre-operative assessment and upheld this complaint.

Finally, Mrs C complained that she had been discharged from hospital without antibiotics. We took independent advice from a dental adviser. We found that it had been standard practice and reasonable to discharge her without antibiotics. We did not uphold this complaint.

Recommendations

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

• The documentation that is completed at a pre-operative assessment should include a section for any concerns raised at that assessment.
• Pain relief medication prescribed should be appropriately recorded. All medicines on discharge should be clearly and accurately recorded on discharge documentation.