Decision Report 201507849

  • Case ref:
    201507849
  • Date:
    August 2016
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C attended A&E at Glasgow Royal Infirmary following a sports injury. On discharge he was advised to take painkillers and use an ice pack. Mr C was later referred back to the hospital as he was continuing to suffer pain. Mr C complained to the board about his treatment but the board said that the examination, diagnosis and management plan he received at the time of his injury were appropriate.

Mr C complained to us that his condition had not been reasonably assessed by the hospital. We took independent advice from an emergency nurse practitioner. They found that although Mr C had been examined, there were shortcomings. Mr C's medical records did not properly record 'when, how, where, what and why', including the time of the injury and the advice given to Mr C about what to do should his pain continue. Had this advice been given, Mr C may have returned to hospital sooner and been given an earlier diagnosis. We upheld the complaint.

Recommendations

We recommended that the board:

  • make a formal apology; and
  • ensure that our findings are made available to the member of staff concerned and that they review the Nursing and Midwifery Council code in relation to record-keeping.

Updated: March 13, 2018