The Health and Disability Commissioner has recommended that a Health Board carry out an audit, implement new processes, and provide staff further education after systemic issues resulted in a failure to chart and provide a patient’s medications.

The patient was admitted to the emergency department. While in the emergency department, the man’s details and regular medications were recorded. However, upon being examined and transferred to the surgical unit, his regular medications were not recorded.

The failure to record resulted in the man not being provided his medications for the four days he was in the hospital.

Although the patient didn’t suffer any harm, the investigation carried out by the Commissioner exposed systemic issues within the hospital.

Highlighted was the lack of any formal process of charting regular medications of patients moving between the emergency department and surgical unit.

The Commissioner held that the failure of the hospital staff to chart and provide the man’s regular medications was a breach of his right to have services provided with reasonable care and skill.

The Commissioner recommended that the Health Board apologise to the patient, audit previous patient transfers for whether medications were recorded, develop a checklist and action plan for transfers between the two departments, provide evidence of the development and implementation of a Surgical Ward Round Form, and to report back to the Commissioner about additional staffing.

Had the Health Board had robust systems in place for rudimentary patient transfers, the entire incident could have been avoided.

If there are concerns that health professionals have failed to provide you their services with reasonable care and skill, it is wise to speak with a professional experienced in the area.

Leading law firms committed to helping clients cost-effectively will have a range of fixed-priced Initial Consultations to suit most people’s needs in quickly learning what their options are.  At Rainey Collins we have an experienced team who can answer your questions and put you on the right track.


Alan Knowsley