An investigation by the Ombudsman into the treatment of a patient at Tralee General Hospital found "a stark failure" by medical staff to keep detailed medical records.
The Ombudsman, Mr Kevin Murphy, mentioned the case when speaking to health service employees on how best to handle complaints.
He said the Tralee case revealed deficiencies in the manner in which the hospital handled a complaint from a family whose father was admitted with severe pain in his lower back and legs. He was examined by doctors but remained in pain. His family continually sought explanations. Their father was subsequently transferred in an emergency to another hospital, where he died shortly afterwards of a ruptured aneurysm.
Mr Murphy found there was a lack of emphasis on the family as human beings. They were sent around in circles when they complained, and there was "a paucity of records covering critical treatment junctures".