Decision Report 201200437

Summary

Ms C has multiple allergies. In September 2011, she was admitted to hospital with severe abdominal pain and vomiting. She was diagnosed with appendicitis and had an operation later that day. The surgeons found that the appendix had ruptured and she had peritonitis (inflammation of the tissue lining the abdomen). The consultant anaesthetist noted that she had at least one anaphylactic shock (a severe, potentially life-threatening allergic reaction) the day after the operation. A week later, her condition deteriorated and she needed another operation.

Several days after being discharged, Ms C was re-admitted to hospital with abdominal pain. She was discharged the next day and staff arranged for her to be seen as an out-patient. In December 2011 she was admitted again with abdominal pain and vomiting. She was prescribed two forms of pain relief and an antibiotic and considers that she had an anaphylactic shock as a result. Ms C was discharged just over a week later to attend the pain and surgical clinic as an out-patient. She was admitted to the intensive care unit at the hospital at the end of February 2012 following an anaphylactic reaction to a barium solution (a liquid used when carrying out scans and x-rays) in the x-ray department. She told us that she also had further reactions to medical wipes.

Ms C complained that as a result of the board’s failures, she endured a second avoidable operation, and developed hernias, constant abdominal pain and abnormal bowel movements. She said she had a number of anaphylactic attacks, which were avoidable had staff taken reasonable steps to prevent them. She also complained that while she signed consent forms, she was not physically or mentally capable of giving consent to treatment, and raised concerns about the way the board handled her complaint and the delay in responding.

After taking independent advice from two of our medical advisers, a surgeon and a nurse, we did not uphold Ms C's complaints about her care and treatment. The advice we received and accepted was that the care and treatment she received in relation to the operations, including post-operative care, was reasonable. There was clear evidence that she consented to both operations and that staff communicated with her and her family, although the family felt that this did not meet their needs. In relation to the complaint about her care while an out-patient, particularly in relation to her allergies, on the whole we found that the care and treatment was reasonable. We found that the medical assessments and notes contained many references to Ms C's allergies, although we noted the board had acknowledged that radiology staff had not received information about these and had taken steps to address this.

We did, however, uphold her complaint about the complaints handling. We found that the board had carried out a thorough investigation of Ms C's complaint and responded to all the issues raised. However, they took eight months to do so. Ms C had agreed with the board that they would respond to all her complaints in one letter, although it was not clear when this happened. This approach had made the delay worse, however, as draft responses were prepared but not issued. We noted that each time Ms C had raised further complaints, the board had started a fresh investigation. We took the view that they could and should have managed this better.