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Case ref:201201403
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Date:June 2014
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about the care and treatment she received when she was admitted to Aberdeen Maternity Hospital to have her baby via an elective caesarean section (a planned operation to deliver a baby). The plan was for Mrs C to have spinal anaesthesia, but staff were unable to numb her spinal area. Mrs C complained that she was in extreme pain and that she asked staff to stop, but they did not listen to her and persisted in trying to provide spinal anaesthesia. Mrs C said that the pain stopped only when she was given a general anaesthetic.
We took independent advice on this complaint from one of our medical advisers. All the available information was taken into account, including Mrs C's clinical records and the complaints correspondence.
Our adviser said that spinal anaesthesia is a technique with a recognised failure rate. The clinical records indicated that the complications of the procedure were explained to Mrs C and alternatives were discussed with her. The adviser also said that the attempts to site the anaesthetic were made by appropriately experienced anaesthetists and the records showed that, given the particular depth of the space in Mrs C's body where they were trying to place the anaesthetic, any attempt to do so would be technically challenging. The records also indicated that because Mrs C wanted to avoid having a general anaesthetic, the anaesthetists persisted in trying to site a regional anaesthetic, and when Mrs C declined the option of awaiting labour, further attempts to site the regional anaesthetic were made. We found no evidence of any significant shortcomings in the management of Mrs C's care. However, we found that the record-keeping was not to an acceptable standard, as it did not conform to Association of Anaesthetists of Great Britain and Ireland guidance and we made a recommendation about this.
Recommendations
We recommended that the board:
- remind anaesthetic staff involved in this case of the importance of maintaining comprehensive records in line with the relevant guidance.