Decision Report 201405904

Summary

Mr C complained that he had not received appropriate care following an operation on his urinary tract. He said that because the consultant had not examined him appropriately at a post-operative consultation, the consultant did not realise that Mr C's condition had deteriorated. Mr C said that meant that he was in significant discomfort until a further consultation six months later, when the problem was identified and he underwent a further operation. He was then taught a technique for self-help which aimed to support the work of the operation, to avoid a further recurrence. Mr C complained that the board had not referred him for this self-help technique after his first operation.

We sought independent advice from a urology consultant. Our adviser noted that there was limited information on file about what happened at the post-operative consultation, but that given the concerns expressed by Mr C (and referred to in the records) it would have been reasonable for the consultant to have examined Mr C in more detail, and undertaken various tests to identify how his condition had changed. Our adviser was critical of this, and of the limited information in the notes from the consultation. However, our adviser also noted that while some consultants may sometimes refer patients to the self-help technique after a first operation, it was reasonable that Mr C was not taught this until after his second operation.

We were critical of the level of follow-up Mr C was given following his first operation, particularly given the concerns he raised during his consultation. We noted that, while the clinical notes provided limited information about what was discussed, we were satisfied that Mr C raised concerns which were not sufficiently investigated. We were also critical of the level of record-keeping.

Recommendations

We recommended that the board:

• highlight the findings of this investigation to the consultant involved, and remind him of the General Medical Council's requirements in relation to record-keeping; and
• apologise to Mr C for failing to provide an appropriate level of treatment during his first post-operative consultation.