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Case ref:201405825
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Date:February 2016
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Body:Lothian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C and his father (Mr A) complained about the care and treatment provided to Mr A in relation to an operation to fit a pacemaker. They were unhappy about treatment Mr A received at the Royal Infirmary of Edinburgh when the pacemaker was fitted and said that there was inadequate information about possible complications of the surgery and incorrect treatment during the surgery. They also complained about the response and aftercare following surgery when Mr A reported his levels of pain and concerns. They said that as a result of the failures, Mr A's quality of life had been adversely affected and that he had to undergo another operation to repair the incorrectly positioned pacemaker.
We took independent advice from a medical adviser. We found that there was no evidence that sufficient information was given to Mr A about the procedure and possible complications or that staff took account of his additional needs (given his anxiety and loss of hearing). We also found that while there were problems with the pacemaker that had to be rectified, this does not mean that it was incorrectly implanted in the first place. Having said that, we were critical that staff failed to address Mr A's anxiety or ensure he was adequately sedated which may have contributed to an increased likelihood of lung puncture during the procedure. Moreover, while we found that clinical staff dealt with Mr A's concerns technically following the operation, staff failed to address his anxiety which may have exacerbated his symptoms. We therefore upheld the complaint and made a number of recommendations.
Recommendations
We recommended that the board:
- review their procedures around consent and ensure that the process accommodates patients with additional needs;
- bring the failures related to consent and additional needs to the attention of relevant staff;
- bring the failures related to managing anxiety during the surgical procedure to the attention of relevant staff;
- ensure relevant staff consider referral to rehabilitation in similar circumstances; and
- apologise to Mr A for the failures this investigation identified.