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Case ref:201202397
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Date:December 2013
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Body:Ayrshire and Arran NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C, who is a claims assessor for an insurance company, contacted us on behalf of her client (Mr A). Mr A was concerned that an operation to fix a fracture to his upper leg had failed and he was left with a shortened leg as a result. He thought that this was because a junior doctor was allowed to complete the operation unsupervised, and said that follow-up physiotherapy had only caused him additional concerns when the fracture re-opened. Mr A also believed he suffered a morphine overdose at the time of surgery which left his health additionally compromised and contributed to a post-operative problem with blood clots.
We took independent advice on this complaint from three of our medical advisers specialists in orthopaedics, anaesthetics and physiotherapy. The orthopaedic adviser said that the surgery was not performed to an adequate standard, although not because of a lack of supervision. The adviser noted that during the operation there had been difficulty inserting screws to fix the fracture, and ultimately these had not been placed correctly. This was a recognised complication, but one he felt should have been identified at the time. He was concerned that there was no record showing that the possibility of the leg being left shortened was discussed with Mr C beforehand. The dosage of morphine was not considered to be unreasonable in the circumstances of the trauma Mr C had suffered, although it was clear that he had suffered a recognised side-effect from it. The physiotherapy problems were considered to be an inevitable consequence of the failed surgery, but not unreasonable in all the circumstances. We upheld the complaint about the standard of surgery but not those about supervision or physiotherapy.
Recommendations
We recommended that the board:
- provide evidence that their new consent form is now routinely used and includes space for noting all risks discussed; and
- remind surgical staff of the need to make a comprehensive note of operations, particularly where adverse technical problems have arisen, so that subsequent review is possible.