Poor nursing documentation in patient's records

Summary 842 |

Mr W complained about the care and treatment his late mother received while she was an inpatient at the Trust. He also said that his complaint was handled dismissively and not all the issues were addressed.


What happened

Mrs W was in her eighties and admitted to the Trust after having had a seizure at home. She was cared for in a side room because of her recent history of infections. Some two weeks after admission, she was transferred to a community hospital. Her condition deteriorated and she died soon after.

Mr W raised a number of concerns: his mother was left dehydrated; she suffered with infections acquired in the hospital; she was not appropriately tested for infections; and that general poor nursing contributed to her death.

What we found

We partly upheld this complaint. There was no evidence to support Mr W's assertions about poor care, or infections acquired in hospital.

But we agreed there were failings in respect of poorly completed nursing documentation, which meant that Mrs W's needs were not clear when she was transferred to another hospital. This raised concerns about the Trust's record keeping.

Mr W also made a complaint about information a doctor at the Trust gave him, but this had not been followed up, because the doctor concerned was on leave at the time of the local resolution.

Putting it right

The Trust created an action plan to address the identified failings around the record keeping. It also provided further information about the outstanding issue regarding a doctor who allegedly gave erroneous information to Mr W.

Health or Parliamentary
Health
Organisations we investigated

University Hospitals of North Midlands NHS Trust

Location

Staffordshire

Complainants' concerns ?

Did not take sufficient steps to improve service

Result

Recommendation to learn lessons or draw up an action plan

Taking steps to put things right