Decision Report 201202537

Summary

Mrs C's mother (Mrs A) suffered a stroke after undergoing surgery for a fractured hip. Mrs C complained that the operation had taken too long and that her mother was not provided with a reasonable level of care during and after the surgery. She also believed that her mother did not receive adequate treatment after the stroke was diagnosed, as she did not receive a scan to confirm the diagnosis and was not moved onto a stroke ward.

After taking independent advice from one of our medical advisers, we upheld the first complaint as we found that the operation to repair Mrs A's broken hip did not follow best practice. She was not operated on within the 24-hour time limit set out in Scottish Intercollegiate Guidance Notes (SIGN), and the fit of the artificial hip was not properly checked, which meant the operation took 45 minutes longer than planned and unnecessarily increased the risks to Mrs A during surgery. We found that the board had not acknowledged or investigated these failings sufficiently in their investigation of Mrs C's complaint.

We did not uphold Mrs C's other complaints as we found no evidence to show that Mrs A was inappropriately discharged from the recovery room to a ward when she failed to recover from the anaesthetic, nor that her treatment was not reasonably managed when it was realised that she had suffered a stroke.

Recommendations

We recommended that the board:

• provide evidence that staff have been reminded about the importance of using trial stems prior to the insertion of cement during arthoplasties (a surgical procedure that restores the function of a joint);
• remind all staff of the importance of the 24-hour safe period set out in SIGN guideline 111;
• remind all staff of the importance of making clear, accurate notes for all clinical decisions; and
• apologise in writing for the failings identified in our investigation.