Decision report 201100718

Summary
Ms C had a planned operation to remove cysts, uterus, tubes and ovaries. The operation was performed under a general anaesthetic. During surgery, the cysts were not situated as had been thought from the scans and the surgeon decided not to remove these. After the operation Ms C were given morphine for pain relief but she had an adverse reaction to this and further drugs were administered to reverse the effects of the morphine. Following the operation, further scans were arranged to assess the exact position of cysts and a second operation to remove the cysts was carried out five weeks later. This operation was carried out under epidural anaesthetic.

Ms C complained about the timing of her operations and the after care she received in relation to the pain relief prescribed. She also complained that staff failed to remove the clamp from her catheter within a reasonable time causing pain. She also complained that they failed to record medication given which meant that staff attempted to give her analgesia twice.

We found that the timing of the operations were reasonable, as was the anaesthetic provided. However, we found that the board's failures to remove the clamp from Mrs C's catheter within a reasonable time and to record medication given were potentially very serious failures. We did not make any recommendations in light of the action the board had already taken to address the complaint.