Decision Report 201202393

Summary

Ms C contacted us on behalf of her client (Mr A) who was unhappy with treatment he received during a hospital consultation. She said that Mr A was not provided with the correct treatment and procedures were not properly explained to him beforehand.

After taking independent advice from one of our medical advisers, we did not uphold the complaint about treatment as we found that it was reasonable given the symptoms he reported. We did, however, uphold the complaint about the explanations provided. The board told us that patients are fully informed verbally before the consultation, that they are sent a leaflet in advance by post and that Mr A had given verbal consent to the procedure. Mr A disagrees, and there was insufficient evidence for us to reach a decision on whether reasonable verbal information was in fact provided beforehand. We found that the board had no written record or evidence that the procedure was explained to Mr A, or whether he had been sent a leaflet or given verbal consent. Because of the lack of clear evidence that the board had adequately explained this to him, we upheld the complaint.

Recommendations

We recommended that the board:

• carry out a review of the patient's pathway when attending the relevant clinic, with a view to improving documentation and record-keeping to incorporate a record of all advice given, acknowledgement that the patient understands the advice and that consent had been given; and
• consider revising the appointment letter to either incorporate the information leaflet or clarify that a leaflet is enclosed.