Decision report 201105498

  • Case ref:
    201105498
  • Date:
    January 2013
  • Body:
    Lothian NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    admission, discharge and transfer procedures

Summary

Mr C complained about the care and treatment that his father (Mr A) received when the board referred him to a private hospital as an NHS patient for an operation. Mr C said that his father's discharge from the hospital was unreasonable, as he had not passed urine. He also complained that his father was discharged in severe pain with pain relieving drugs co-codamol and paracetamol, despite the fact that he had told the hospital he could not take co-codamol as it contained codeine. A nurse had recorded in Mr A's notes that he had passed urine before being discharged. In response to the complaint, the nurse said that although she could not remember Mr A, she had noted this in the records, and he would not have been allowed to leave the hospital had he not done so. We found that there was no evidence to support Mr C's complaint that the record had been falsified. However, we found that Mr A was prescribed co-codamol in error, as the hospital had previously recorded that he was not to be given codeine. We upheld this complaint and made recommendations to address this. Mr C also complained that the hospital's response was unreasonable when his mother contacted them about his father's pain after his discharge. We found no evidence to support this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

  • issue a written apology to Mr A for administering co-codamol in error; and
  • review this matter in order to identify how they can prevent such errors.

 

Updated: March 13, 2018