Medical negligence partner and former nurse Olive Lewin, reflects on a nurse’s actions as she is suspended for altering medical notes.

A nurse has recently been suspended from the NMC (Nursing Midwifery Council) register for a year after she falsified a patient’s records in the A&E department at the Whittington Hospital.

The Council heard that Nurse Sendijja was supervising a student nurse who had carried out an assessment on a patient in A&E.

The patient was drunk and had fallen and hit his head. The student nurse assessed the patient and recorded the Glasgow Coma Scale as being 8. The normal level is 15. The Glasgow Coma Scale is a neurological assessment of impairment of conscious level, and is a method used following a head injury, or any other neurological injury or insult involving the brain.

The assessment consists of eye, motor and verbal responses, and each response is given a score. It is crucial to carry out assessments on a timely basis, and to report any abnormal signs immediately to a doctor.

Nurse Sendijja was informed by her student twice of the abnormal findings, but did nothing about them.

Eventually the patient vomited and was attended by a senior nurse and doctor. He was rushed to the trauma department with a brain haemorrhage.

The subsequent assessment would have been hampered as Nurse Sendijja crossed out the scores recorded by the student nurse, and discarded the old notes replacing them with new notes. A one year suspension was deemed appropriate.

Having dealt with many brain injury cases I know how important it is that accurate medical notes are kept. Poor record-keeping can lead to critical delays in the appropriate treatment of patients. It is particularly important that patients with a head injury are assessed correctly.