Emergency department failed to record prescribed medication

What happened

Miss G went to the Trust's emergency department three times in 15 days with chest pain and other symptoms such as vomiting, loss of appetite and dizziness. On each occasion, staff carried out chest X–rays and blood tests. Trust staff found no cause for concern the first time Miss G went to the emergency department and did not prescribe medication. At the second visit, staff diagnosed Miss G with a viral chest infection and gave her painkillers. At her third visit, clinicians found Miss G had pneumonia and prescribed antibiotics and antisickness medication.

Miss G complained that the Trust should have diagnosed her pneumonia sooner. She also complained that there was no record in her notes about the fact she had been vomiting, even though she was prescribed antisickness medication.

What we found

We partly upheld this complaint. The Trust had made a reasonable diagnosis on each occasion. Although there was an appropriate record of Miss G's history of vomiting, we were concerned that there was no record of the antisickness medication that the Trust had admitted prescribing.

We did not consider that this led to any harm to Miss G, but we were concerned about the implications of this poor record keeping for other patients.

Putting it right

The Trust shared our investigation finding with all emergency department staff who prescribe medication.