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Mr and Mrs Q complained about the care and treatment Mr Q had received as a patient at Glan Clwyd Hospital and Wrexham Maelor Hospital.

Having reviewed the evidence I found that during Mr Q’s admission to Glan Clwyd Hospital on 17 and 18 May 2011 the “In-Patient Medication Administration Record” had not been appropriately completed. As a result, it was unclear whether Mr Q had received any of his Parkinson’s disease medication.

With respect to Mr Q’s discharge from Wrexham Maelor Hospital on 22 May 2011, I found that the medical records for this period failed to fully reflect Mr Q’s anxious and difficult behaviour, the actions taken by staff to reassure him, any medical reviews undertaken by doctors or need to call a security officer. As a result Mr Q was discharged from hospital without assessment, placing Mr and Mrs Q in a vulnerable position.

I recommended that the UHB apologise to Mr and Mrs Q for the failings identified in the report and pay them £750 in recognition of the service failure and the time and trouble in bringing their complaint to this office. I also recommended that the UHB:

• Review Mr Q’s “In-patients Medication Administration Record” for the period 17-18 May 2011, and where appropriate instigate the UHB’s “Medicines Management Assessment Workbook and Competencies” document, in accordance with the UHB’s procedure.

• Review Mr Q’s medical records for the period 19-22 May 2011 and where appropriate take action in accordance with the UHB’s procedures.

• Remind the relevant staff that in the event that a security officer is called an “Incident Recording Form” should be completed.

• Bring the updated discharge protocol to the attention of the relevant staff and introduce discharge drop in sessions at the Second Hospital.

• Produce a training plan ensuring that within 12 months all relevant staff at the Hospital receives training on record keeping.

A copy of the full report is available below.