The complaint related to the standard of care provided to Mr C at the ED at Morriston Hospital following a fall at home which caused a head wound. The Ombudsman’s investigation considered whether Mr C should have had a haemoglobin test, or additional investigations or monitoring, before discharge home.
A patient with a head wound with a clear Computerised Tomography (‘CT’ – using computers and images to provide a more detailed image of the body) head scan, and no ongoing bleeding, can be discharged home. However, in Mr C’s case there were additional risk factors due to his age and comorbidities (Mr C had previously been treated for blood cancer (myeloma) as well as a heart attack for which he took anticoagulant medication to help prevent his blood clotting). These required additional consideration and observations which were not evidenced in the clinical records; of particular significance, there was no record that Mr C’s bleeding had stopped, or details of his previous haemoglobin level. Without this information, it was impossible to determine whether it was clinically reasonable to discharge Mr C at that point. However, the absence of any documentation to show that these relevant factors were fully considered before Mr C was discharged was a failing. The Ombudsman upheld the complaint and made several recommendations.
The Health Board agreed to apologise to Mr C’s family, and review its ED practices given comments made by the Ombudsman’s Adviser, including the use of a head injury proforma, recording ongoing observations and record keeping.