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Case ref:201407332
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Date:January 2016
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained that the board unreasonably failed to repair a hernia (where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) above his navel during surgery at Glasgow Royal Infirmary. He said that, after the operation, his hernia was still in place and the scar from the operation was located below his navel, rather than above it. Mr C was concerned that his hernia had not been operated on at all. He said that he repeatedly asked to speak to a member of the operating team about this but no one came to see him. Mr C also said that the board provided an inadequate response to his complaint.
We obtained independent medical advice from a consultant in general and colorectal surgery. The adviser said that the notes of Mr C’s original operation, together with the notes from the operation to finally repair the hernia the following year, indicated that the consultant did operate on the hernia above Mr C’s navel during the original operation. The adviser said that the location of Mr C’s surgical scar below his navel did not mean that his hernia was not operated on. The adviser explained that it was standard practice to make an incision in the natural skin crease just below the navel when repairing a hernia around the navel. However, the adviser said that Mr C’s hernia was inadequately fixed as it was present after his surgery.
We considered that the evidence in the nursing notes suggested that Mr C did ask to speak to a member of the surgical team after his operation. We accepted the adviser’s view that there was a failure by the board to communicate with Mr C at this time. We also found that the board did not appropriately investigate and address each element of Mr C’s complaint.
Recommendations
We recommended that the board:
- take steps to contact the consultant and feed back our decision on this case;
- feed back the failing identified in Mr C's complaint about complaints handling to the staff involved; and
- provide Mr C with a written apology for the failings identified in our investigation.