In this month’s edition of the Ombudsman’s findings, we discuss the importance of record keeping.
This month we published decision reports from 11 complaints investigated by the Ombudsman, all relating to health services. The outcome of these 11 complaints were
- Fully upheld: 8
- Some upheld: 2
- Not upheld: 1
We made 25 recommendations to public bodies.
Record keeping
This month we published a number of reports that highlighted concerns around record keeping. Poor record keeping can make it difficult to fully understand what has happened and can impact the quality of care.
In one case, we found that a health board failed to provide basic nursing care to a patient. Appropriate assessments did not appear to have been carried out or documented during the admission.
We asked the board to apologise to the patient’s family and ensure that nursing documentation is completed to the required standard. We also noted that the board had identified areas for improvement through their own review of the case.
In another case, while we concluded that the care and treatment provided to a patient for a tooth extraction was reasonable, the dental practice’s record keeping fell below the required professional standards. We upheld the complaint but made no further recommendations, as the dentist involved had appropriately reflected on their practice.
Good record keeping plays an important role in safe, effective health care. While standards fell short in these cases, it is encouraging that the organisations involved took the opportunity to reflect on their practice and identify areas for improvement.
Taking complaints seriously helps to strengthen trust in public services and supports continuous learning.