Decision report 201104862

Summary

Mrs C complained about the care and treatment she received during a three-week hospital admission. Mrs C was admitted for an endoscopic retrograde cholangiopancreatogram (ERCP - a procedure where a flexible tube is passed into the small intestine) and believed that she would be discharged the same day. She said that she had to change for her surgery in a supply room, and that nursing staff were unaware of her whereabouts when the theatre porter came to take her to surgery. She also said that there was no pre-operative discussion or explanation of her impending surgery, no consultation about possible complications and risk factors, no explanation of the forthcoming surgical procedure, and no formal introduction to the surgeon or the surgical team. The procedure was difficult and a significant complication developed which meant that Mrs C remained in hospital for three weeks. The procedure proved difficult because of the narrow opening of her bile duct. She also underwent a sphincterectomy (her sphincter muscles were cut). She developed pancreatitis (inflammation of the pancreas) which caused her severe pain. Mrs C's condition deteriorated and she said that staff failed to recognise this and that her family had to alert them to her deteriorating condition. She was transferred to a high dependency unit seven days after the procedure. She also complained that staff failed to provide appropriate or effective pain control until she was prescribed a morphine pump (a medical device used to deliver pain relief into the spine) nearly two weeks after the procedure, and that the board made inaccurate statements in relation to pain relief and communicating the risks of the procedure.

After taking independent advice from one of our medical advisers, we upheld three of Mrs C's four complaints. Our investigation found that Mrs C was asked to change in a treatment room (not a supply room) and that this should not be normal practice. We noted that the board acknowledged the distress this caused Mrs C and took steps to ensure it did not happen again. We also found no evidence that Mrs C was made aware that pancreatitis is a common complication of ERCP and sphincterectomy, which is unacceptable. We did not uphold the complaint about the standard of post-operative care and treatment Mrs C received, as we found that this was reasonable, including the pain relief regime that was in place. We found that the board had correctly said that while it had been difficult to control the pain in Mrs C's case, appropriate and reasonable pain relief was provided. During our investigation, the board acknowledged that they had misinterpreted the level of discussion between the consultant and Mrs C about the risks of the procedure, and we found that they had inaccurately stated in their response to her complaint that Mrs C was informed about the risks.

Recommendations

We recommended that the board:

• ensure that staff properly inform patients of risks when they are obtaining consent for treatment and that record-keeping reflects this; and
• apologise to Mrs C for the failings identified.