"Really concerned about record keeping, which could be so dangerous"

In late August my elderly father was admitted to the Royal Gwent hospital for a routine prostate operation. Apparently the operation was a success and he was discharged at the start of September. After a few weeks there was a problem with the catheter blocking and the district nurse was called out - sometimes in the middle of the night to unblock it.

In late September the district nurse was called in the evening and at 8.00pm she phoned for an ambulance because the catheter was blocked and she was concerned about fluid retention and swelling in his legs and feet. The ambulance arrived 5 hours later and he was taken to the Royal Gwent Accident and Emergency department. The doctor on duty examined him and said that the urine was now flowing and he was discharged in the early hours. He took a taxi home to an empty house because he lives alone. The following day the district nurse was called at midday, and once again she phoned the hospital and said quite clearly that she wanted him admitted because of the problem with the swelling and the frequent blocking of the catheter. Two hours later an ambulance had not arrived so my brother took him to the hospital. Two hours later he was discharged and taken home.

The next day the catheter blocked again and on this occasion the nurse contacted the hospital and his GP who arranged for him to be admitted. He was taken to the Surgical Assessment Unit and waited several hours to see a doctor. I telephoned the SAU (I live 150 miles away) and spoke to one of the nurses. They said that the doctor had ordered a heart scan and a scan of the urinary tract but because it was unlikely that they could be done that day, they would be keeping him in overnight. I explained to the nurse that my father had suffered from two brain hemorrhages, the latest was only a few years ago, and a number of TIAs that were attributed to small bleeds. The nurse said they would make a note of this on his records. Later that evening he was transferred to a ward and I telephoned the ward to enquire about his condition and to repeat the message about the brain hemorrhages. The person who answered the phone said that they could not see it on his records but would make a note of it.

A couple of days later I travelled down to see my father and spoke to the senior nurse. They told me that there was a problem with his bloods, probably due to the catheter blocking and the urine backing up and they had also found a blood clot in his leg that they were treating with blood thinners. I pointed out the fact that dad had suffered from brain hemorrhages and that the stroke clinic had advised against any blood thinning medication. The senior nurse said that they needed to look at his records and would come back to see me. A few minutes later two doctors from urology arrived and repeated what the senior nurse had told me. When I informed them about the brain hemorrhages they admitted that they did not know about this but would seek advice from the medical team. Five minutes later they returned and said that they would be stopping the blood thinners immediately and because it was a small clot they would leave it to sort itself out. The more senior of the two doctors said that given the information they had available to them at the time they would make the same decision again. As I pointed out - and I feel very strongly about this - the information HAD been made available but either no-one chose to read it, or even worse no-one had bothered to record it on the TWO occasions I had reported it. They said that they would make sure this was put on his records and the senior nurse reassured me that this would be done. They said that they were not working the weekend but would see him again when they returned after the weekend. They asked for the catheter to be removed the next day and this was done.

The following day I received a phone call from my father to say that he had seen the doctor on duty and that they had said that his toe was better and he could go home (I knew he had an ingrowing toenail but this had nothing to do with why he was in hospital). When I arrived at the hospital I spoke to the staff nurse and repeated my fathers phone call. The nurse said that the doctor had looked at his toe and it was okay for him to go home. They said that my father had been a bit difficult on two occasions earlier that morning because he refused to take the aspirin tablets that had been prescribed for him. I explained the situation to them and they said that they were unaware of this because they could not find his medical records. When I went to his bedside, the green nurses folder reinforced this and clearly stated that his records could not be found and that he had refused aspirin. Fortunately, my father is fully aware, but had he suffered from dementia and taken the tablets the outcome might have been different. I asked the staff nurse to please ensure that when they found his records this was clearly written for everyone to see.

My concerns are obvious:

1. Why do staff not record information given to them by patients or their next of kin? During his stay in hospital I reported the fact about my father's brain hemorrhages to FIVE people in total and not one of them recorded this. This is incompetent and in his case downright dangerous. The consequences could have been fatal.

2. Why are records not computerised so that everyone has access to them? As I understand it, currently information is put on bits of paper, hand written and I find this very unprofessional. Expense is often used as an excuse, but because there are numerous ways of making efficiencies within the hospital system, this excuse does not hold water. We are now in the 21st century but many hospital practises and the culture within the hospital itself, seem to be me to be lodged in the 20th century.

3. There is a need to ensure the handover of medical information between staff is more professional. I saw one staff nurse writing notes - brief notes at that - for their replacement who in their words to a colleague "is always late so this will save time". It is easy to see how information can get lost or not recorded at all. At times it appeared that the hospital was run for the benefit of the staff and not the patient (I can give further examples if required).