Decision report 201100090

Summary
Mr C complained about the treatment his wife (Mrs C) received in two hospitals. Mrs C was admitted to the first hospital complaining of groin pain. She also showed signs of infection. Urologists found that Mrs C had a kidney stone preventing her right kidney from draining properly. A nephrostomy (insertion of a small tube to release the urine from the kidney) was attempted but this was unsuccessful.

Staff at the second hospital failed to insert a stent (tube) to drain the kidney the following day but were, with difficulty, able to complete the nephrostomy three days after her admission. Mrs C subsequently developed internal bleeding and was too unwell to undergo surgery. She died seven days after her admission to the first hospital.

Mr C complained that insufficient time was allowed before the first nephrostomy for antibiotics to take effect and resolve Mrs C's infection. He also felt that urology staff spent too much time attempting the first procedure, which he had been told would be quick. It took several hours and, as a result, Mr C believed his wife had been left overnight with internal bleeding. He felt that this delay left insufficient time for staff at the second hospital to treat her.

Mr C raised further complaints about the communication with his wife's relatives; a lack of involvement in decisions about her treatment; and the accuracy of comments made in response to his complaints.

After taking advice from our medical adviser, we found that the nephrostomy was required urgently as failure to provide treatment could have led to Mrs C developing an abscess and blood poisoning. The antibiotics that she was prescribed were also to help prevent blood poisoning. We found that some bleeding was caused by the first procedure but that this was stemmed appropriately. There was insufficient evidence available to determine the cause of her subsequent internal bleeding, but our adviser said that Mrs C had a number of additional medical problems, some of which could have caused this separate to her kidney treatment.

As Mrs C did not have any mental deficiencies that the board were made aware of, we found that it was appropriate for staff to discuss treatment directly with her. The discussions were documented and Mrs C signed consent for each of the procedures carried out. Although the family were not updated until several days after her admission, there was no evidence to suggest that they were denied the opportunity to discuss Mrs C's treatment with staff.

We were satisfied that the board's responses to Mr C's complaints were accurate.