Decision Report 201301814

Summary

Ms C had surgery on her foot to treat bunions at Ninewells Hospital. She complained that the operation did not relieve her pain and discomfort, but made it worse, and so the operation was unsuccessful. After treatment, other possible surgical options were discussed with her, but Ms C was anxious about having further surgery without assurances that she would be properly assessed and treated in future. She was particularly concerned that no x-rays were taken before or after her operation.

During our investigation, the board were unable to explain why they took no

x-rays before surgery. We took independent advice from one of our medical advisers, who said that although it was not mandatory, it was normal practice to take x-rays. Because they were not taken, the adviser was not able to say with certainty whether the procedure Ms C had was appropriate. We were also critical of the board for not properly recording Ms C's consent for the surgery. The procedure carried out was different from that to which she consented and we were concerned that Ms C might not have been properly advised of the procedures involved in this or the potential for failure.

Recommendations

We recommended that the board:

• apologise to Ms C for the failures to x-ray her or record her consent as part of the initial assessment of her suitability for surgery; and
• consider whether there are wider implications for the failings identified in this case, and advise us of the actions taken to address this recommendation and any outcomes.