In this month’s edition of the Ombudsman’s findings, we discuss the importance of accurate record keeping.
This month we published decision reports from 14 complaints investigated by the Ombudsman. Ten of these were about health services, one about health and social care and three about local government. The outcome of these 14 complaints were
- Fully upheld: 12
- Some upheld: 2
We made 44 recommendations for learning and improvement.
Record keeping
A number of our published complaints this month were upheld in relation to a lack of accurate record keeping.
Good records enable organisations to deliver consistent services, explain their decisions, respond to feedback and complaints, and engage in reflective learning.
In one case, a health board had changed the dosage of a patient’s medication on a few occasions but did not record their reasoning for these decisions. We found that the care provided in respect of prescribing and monitoring of the patient’s medication was unreasonable.
We asked the board to remind staff of the importance of appropriate prescribing and ensure that patient’s medical records include all relevant information.
In another case, we asked a council to apologise to a complainant after they did not record enough information to justify their decision on a change to a planning application. Without sufficient records, it is not clear whether the council considered the impact of the change on neighbouring properties.
Being able to give reasons for decisions helps build trust and confidence, and supports transparency in public services.
All our published decision reports can be read in full on our website.