Lost records prevented full understanding of patient care

What happened

Mrs Z was admitted to hospital with a suspected small bowel obstruction. She was initially treated conservatively. However, within three days of admission, her health deteriorated overnight. Urgent surgery, carried out the following morning, identified and repaired a rupture in Mrs Z's bowel, but she continued to deteriorate. She died about a week later.

What we found

Initial conservative treatment was appropriate and in line with the standards and guidelines for the management of small bowel obstruction. However, due to the loss of vital medical and nursing records, particularly relating to the period when Mrs Z's health began to deteriorate, we were unable to say whether or not the treatment given at the point of deterioration was appropriate, or if the Trust should have performed surgery earlier. We found the loss of the records denied Mrs Z's family the opportunity of knowing, through the complaints process, whether everything that could have been done was done, or if the outcome could have been different.

Putting it right

The Trust fully accepted our recommendations and paid Mrs Z's family £500 to recognise the lost opportunity to know what happened to their mother. It also created an action plan to detail the improvements it would make in record keeping.