NHS Borders has issued an apology after a patient was wrongly told they could be discharged following surgery for a broken leg, only to later be informed that further surgery was required due to a scan review error.
The patient, identified as “C” in a report by the Scottish Public Services Ombudsman (SPSO), underwent surgery for a leg fracture and received a follow-up scan the next day. Clinicians initially told the patient the scan showed no problems and that they were fit to return home.
However, days later, NHS Borders contacted the patient to explain that a further review of the scan had revealed an anomaly, meaning additional surgery was necessary. The conflicting information caused distress and confusion for the patient at a time when they were recovering from a serious injury.
Ombudsman Upholds Complaint
After raising concerns directly with NHS Borders and remaining dissatisfied with the response, the patient escalated the matter to the SPSO. The ombudsman sought independent advice from an orthopaedic surgery specialist as part of its investigation.
The SPSO found inconsistencies between a recorded discussion in the patient’s medical notes and a later clinical assessment. The investigation concluded that the most likely explanation was an error in how the initial discussion between clinicians had been documented.
As a result, the ombudsman ruled that NHS Borders had acted unreasonably by reaching different conclusions from the same scan, from the patient’s perspective, and formally upheld the complaint.
Failings in Communication and Record-Keeping
In its findings, the SPSO stressed the importance of accurate medical records and clear communication with patients. It said the inaccurate recording of clinical discussions contributed directly to the patient being given incorrect information about their condition and discharge.
The ombudsman instructed NHS Borders to issue a formal apology and reminded the health board that clinical records must accurately reflect decision-making processes to avoid similar incidents in future.
NHS Borders Response
NHS Borders acknowledged the failings identified in the report and accepted all of the SPSO’s recommendations. A spokesperson said the standard of communication and record-keeping in the case fell below expectations.
The health board confirmed that steps have now been taken to improve internal processes and reduce the risk of similar errors occurring again. It also issued a full apology to the patient for the distress caused.
Wider Context
Patient safety and transparency remain key priorities across NHS Scotland, with health boards under increasing scrutiny over communication failures and record accuracy. The SPSO continues to play a central role in holding public bodies to account when complaints cannot be resolved locally.
Cases such as this highlight the potential impact of documentation errors on patient care and reinforce the need for clear, consistent clinical communication, particularly when discharge decisions and surgical outcomes are involved.