Decision Report 201205333

Summary

Mr C complained that his wife (Mrs C) was not provided with reasonable care and treatment after an operation to remove her womb, ovaries and fallopian tubes at Glasgow Royal Infirmary. He said that Mrs C had received an incorrect amount of morphine (pain relief) after surgery and as a result she stopped breathing and nearly died. Mr C and his son witnessed this and it had caused them both considerable upset. Mr C also said that the board unreasonably handled his complaint about this.

We took independent advice on this complaint from one of our medical advisers, who is a consultant anaesthetist. Our investigation found that Mrs C did not receive excessive morphine. Our adviser said that Mrs C exhibited a recognised but rare complication of a standard analgesic (pain relief) technique, which resulted in her breathing being impaired. We found that hospital staff and clinicians provided the correct care and treatment to Mrs C throughout her stay in hospital and so we did not uphold this complaint. However, we found that staff communication at the time of the incident could have been better, and made a recommendation to improve this.

During our examination of the complaints handling we found a period where the board delayed in contacting Mr C, which they had acknowledged. For this reason we upheld that complaint and made a recommendation.

Recommendations

We recommended that the board:

• advise the Ombudsman on the steps taken to ensure that the communication failures (after the incident, and a misleading entry on the discharge letter) do not recur;
• issue Mr C with a full and sincere apology for the failings identified; and
• advise the Ombudsman of the steps they take to ensure that the complaints handling failures identified in this complaint do not recur.