Decision report 201004237

Summary
Mrs C was admitted to hospital for removal of her ovaries. Complications arose which resulted in an extended stay in hospital. Mrs C complained that the board failed to provide appropriate care and treatment during the first five months of her stay in hospital, which included an injury to her bowel leading to a colostomy, as well as septicaemia, pneumonia, kidney failure and becoming infected with clostridium difficile. Mrs C also complained that for over a year the board failed to disclose to her that an ovary had adhered to her bowel.

Although there is no question that Mrs C suffered serious consequences as a result of the injury to her bowel, resulting in an extended stay in hospital and the need for ongoing care and treatment, we did not uphold the complaint about care and treatment. We found from looking at the medical records, and taking advice from two of our medical advisers, that it was not possible to say definitively how the bowel injury was caused, but it was a recognised complication of abdominal surgery.

Both advisers said it was unlikely that the injury, as the cause of Mrs C's symptoms, could have been identified sooner, and they were satisfied that the board provided reasonable care and treatment. We did, however, conclude that medical records could have been clearer. There was no documentation in the medical records to confirm that Mrs C was given an explanation of the procedure used during, and the findings and outcomes of, the surgery to remove her ovaries. There was no evidence that this information had been deliberately withheld, but the lack of records was not in keeping with the General Medical Council's Good Medical Practice guidance. Given this, we could not conclude that Mrs C was provided a clear and consistent explanation of events and, therefore, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for their failure to provide a clear and consistent explanation of events;
• remind medical staff in the hospital of the need to maintain clear and thorough medical notes, in line with Royal College of Physicians' guidelines on standards for medical record-keeping; and
• remind medical staff of the importance of recording details of explanations given to patients, in line with the General Medical Council's Good Medical Practice guidance.