Decision Report 201300347

Summary

Ms C was operated on at the Western Isles Hospital for a labial abscess (a painful swelling caused by a build-up of pus in part of the female genitals). Ms C had undergone a kidney and pancreas transplant in 2007. She complained that although her medical records said that the transplant team should be contacted prior to any surgical procedures, this had not happened. Ms C said that this had placed her at great risk, as the drugs she took to prevent her body rejecting the transplant suppressed her immune system, meaning she was at increased risk of infection.

Ms C also complained that she was not provided with reasonable care after the surgical procedure. She was discharged, despite being in great pain, and was then readmitted as the wound had become infected. Ms C suggested that she should not have been operated on in the first place and said her view was supported by the fact that on her second admission she was transferred to another hospital for treatment.

We took advice from two medical advisers, a specialist in the management of transplant patients and a specialist in gynaecological surgery (surgery of the female reproductive system). They said that the records showed that attempts had been made to contact Ms C's transplant team. However, the advisers said that the nature of the infection, combined with Ms C's suppressed immune system, meant it would not have been reasonable to delay her operation. They said that a reasonable care plan had been put in place, and the medical record showed that she was free of infection at the time of her discharge.

Our investigation found that Ms C had undergone the appropriate surgical procedure for a labial abscess, and that the care she received after the procedure and the decision to discharge her had both been reasonable. We found it would not have been appropriate to delay surgery whilst awaiting the response of the transplant team. Our investigation also found, however, that the attempt to obtain advice from the transplant team was not followed up, which would have been appropriate, so we made a recommendation about this.

Recommendations

We recommended that the board:

• remind all staff of the importance of obtaining advice from the appropriate specialist transplant unit when treating patients who have a compromised immune system as a consequence of transplant surgery.