Summary
C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital.
When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2.
We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint.
We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failing identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future: A system is in place which ensures when advice is provided by the board for tertiary patients there is a record of this as a permanent part of that patient’s electronic record.
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.
Related reading
View Decision Report 202301188 as a PDF (26.5 KB) Updated: December 18, 2024