Decision Report 201405461

Summary

Ms C complained that the board failed to adequately manage her Von Willebrand Disease (VWD – an inherited bleeding disorder) when she was admitted to Aberdeen Royal Infirmary for gall bladder surgery. She said she had previously been given medication for her VWD before dental treatment and treatment for cancer, but said this did not happen for her gall bladder surgery. Ms C also complained that the board failed to communicate properly with her about her VWD when she was in hospital.

We obtained independent medical advice on Ms C’s case from a consultant haematologist with specific expertise in blood clotting disorders. Our adviser said that Ms C’s VWF levels (levels of a blood protein which helps blood to clot) were checked on the day of her surgery and found to be within the normal range. As a result, the board decided not to treat Ms C with a concentrated form of the clotting agent, but to have it ready in case any problems arose. Our adviser said that this approach was reasonable.

The board apologised for the lack of communication with Ms C about her VWD and said that staff should have explained and discussed her condition with her. Our adviser said that communication could have been improved by checking Ms C’s VWF levels the day before surgery, rather than on the day of her surgery, and making a decision on whether she required treatment with the concentrated form of the clotting agent at that time. This would have allowed more time for discussion with Ms C about VWD and the proposed treatment, and at a less stressful time than on the day of her operation. This would have increased the chances of Ms C understanding and accepting the apparently conflicting advice about the management of her condition. We were critical of the board in this regard.

Recommendations

We recommended that the board:

• feed back our decision on the complaint about the board's communication regarding VWD to the staff involved.