Clinical treatment in hospital
Upheld in whole or in part
Non-public interest report issued: complaint upheld
Aneurin Bevan University Health Board
Mrs L complained about the care and treatment that her husband, Mr L, received from the Health Board on 18 November 2021. She complained that Mr L’s chest pains were not appropriately investigated, that he should not have been discharged home without exploring his raised blood pressure and his risk of heart problems, and that the standard of record keeping was poor.
The investigation found that the brief and isolated nature of Mr L’s chest pain did not indicate a serious heart problem and it was not necessary for him to undergo further investigations. Although his blood pressure should have been re-checked before his discharge, it would probably not have altered his eventual outcome and it was appropriate to refer him to his GP for follow-up. These complaints were not upheld.
However, the investigation also found that the record of Mr L’s attendance was very brief, and the documentation was incomplete. Whilst the investigation was able to consider and draw conclusions about the care provided, clinical records should be complete so that a full picture of the clinical rationale is clear. The absence of this was an injustice to Mrs L because more comprehensive documentation might have provided her with some comfort and reassurance that Mr L received a considered and thorough assessment. This element of the complaint was therefore upheld.
The Health Board agreed to apologise for the record keeping, share the report with the Doctor who discharged Mr L for him to reflect on the findings, and remind relevant staff of the importance of maintaining comprehensive records.