A WOMAN cancelled her hysterectomy operation at the Borders General Hospital after being told her medical records had been lost.
The patient, who was also concerned over the range of treatment options she was offered and the management of her condition, lodged an official complaint with the board of NHS Borders.
But dissatisfied with the response – which accepted the record
s had been lost, but only for two days – she brought her complaint to the office of Professor Alice Brown, the Scottish Public Services Ombudsman.
Now, more than a year later, the watchdog has upheld the complaint about the missing files and concluded that administration and staff communication at the BGH were “poor”.
In her determination, Professor Brown claimed it was more accurate to say the clinical records of the patient – referred to as Mrs C – were unaccounted for over a 25-day period.
“Given the importance of the information contained in patient files and its relevance in ongoing care and maintaining confidentiality, it is imperative that staff at the hospital know at all times where to access the clinical records.
“I consider the loss of the [patient’s] records, for whatever duration, to be a failure in what is a crucial record-keeping procedure. I therefore uphold this complaint.”
Professor Brown, a leading political academic, recommended that the board reviews its record-tracking procedures and ensures all staff are reminded of their responsibilities in updating the tracking system whenever records are forwarded to another party.
And she acknowledged the board had “accepted the recommendation and will act on it accordingly”.
But Professor Brown dismissed three other complaints levelled against NHS Borders by Mrs C.
These involved allegations she was given conflicting information about her iron levels, that staff did not acknowledge the severity of her gluten intolerance and that they inappropriately recommended a hysterectomy as the best treatment for her condition.
The report explains that Mrs C had “a complex medical history” and had been referred to the BGH with a fibroid (a benign tumour) on her uteris.
“She also suffered from erythrocytosis (an increased level of red blood cells which can lead to a thickening of the blood) and an apparent intolerance to gluten.
It was during her second consultation at the haemotology department on April 3, 2007, that she was told by her consultant that her clinical records were not available.
She later cancelled the hysterectomy which had been scheduled for April 19.
“The loss of her records concerned Mrs C,” said Professor Brown. “She was unhappy important information about the treatment she had received to date and other conditions she suffered from were not available to consultants, hindering the treatment process.
The full article contains 449 words and appears in Southern Reporter newspaper.