Decision report 201005329

Summary
Ms C, an advice worker, complained to us on behalf of Mrs A, about the board. She said that they had failed to respond appropriately to Mrs A's sudden drop in blood pressure following an operation on her eye under general anaesthetic.

During the post-operative period of the eye operation, Mrs A was unable to breathe and her blood pressure fell dramatically. The board said that she had suffered a primary cardiac event and developed pulmonary oedema (excessive fluid in the lung airspaces). She had to be transferred to the intensive care unit and was put on a life support machine. Mrs A was eventually discharged two weeks later, but now has permanent double vision and vocal problems.

Our investigation found that Mrs A had suffered an obstructive pulmonary oedema whilst awaking from general anaesthetic. This can happen when a breathing tube is removed after an operation. It is not primarily caused by heart failure, however, the resulting fall in oxygen levels had secondary effects on Mrs A’s heart. At the time, the condition could not have been specifically identified as either a primary breathing or primary heart event. However, we found that the management of it and the resulting heart problems was appropriate and timely. This complaint was, therefore, not upheld.

However, we did uphold Ms C’s complaint that the board failed to provide a consistent explanation of what happened to Mrs A. The board had accepted that Mrs A had received conflicting statements from clinical staff about what happened during and following her eye procedure. They had apologised for this and had told Ms C that staff would be reminded of the importance of providing accurate patient information at all times.