Overview
The complainant (Ms C) raised a number of concerns about the way the relevant medical history of her late partner (Mr A) was initially obtained by Borders NHS Board (Board 1) and provided to Lothian NHS Board (Board 2). She also complained that prior to the decision to operate, Board 2 failed to obtain a full medical history from Mr A and that had they done so, the operation may not have proceeded.
Specific complaint and conclusions
The complaint which has been investigated is that Board 1 and Board 2 failed to ensure all the relevant medical history was obtained prior to the decision to operate on Mr A. There are two elements to this:
- (a) Board 1 failed to ensure all relevant medical history was provided to Board 2 (not upheld); and
- (b) Board 2 failed to ensure a full medical history was obtained during the consultation prior to surgery (upheld).
Redress and recommendations
The Ombudsman recommends that Board 1:
- (i) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.
The Ombudsman recommends that Board 2:
- (ii) apologise to Ms C for the failures identified;
- (iii) ensure Consultant 2 reflects on this report so he can review his practice on taking patients' medical history, including when it would be appropriate to request full medical records; and
- (iv) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.
The Board 1 and Board 2 have accepted the recommendations and will act on them accordingly.