Patient's concerns could not be investigated because his records had been destroyed

What happened

Mr A went to hospital after he fell over. Staff told him to go to a nearby hospital to be seen by the maxillofacial team, who treat injuries to the mouth and jaw, as they suspected that he would need specialist treatment.

Mr A went to the second hospital, where he recalls he waited for over an hour to be seen. He was moved to the minor injuries unit but had to wait another hour before he was assessed by a maxillofacial doctor. The doctor told him it was too late to save one of the teeth that had come out. Mr A told staff about other injuries and had a dental X–ray but it appears that he was discharged without further treatment.

Mr A complained to the Trust about his care and treatment, and came to us when he was not satisfied with the Trust's response.

The Trust told us that the records of Mr A's visit to hospital had been destroyed. This made a robust investigation impossible as we did not have any evidence other than Mr A's recollection and that of the doctor to consider.

What we found

We upheld Mr A's complaint about the Trust because its failings denied him the opportunity of resolving his concerns through the NHS complaints process. As a direct result of the destruction of the records, we could not carry out a robust investigation. However, we were pleased to note that the Trust has changed its policy and this should prevent similar situations happening again.

Putting it right

The Trust apologised to Mr A and paid him £500 to acknowledge that its failure to provide us with the records had denied him the opportunity to have his care comprehensively reviewed independently.