Decision Report 201503956

Summary

Mrs C complained of continual abdominal pain and she had a scan. The scan showed a rotation in her gut and, as it was unclear whether or not this was the cause of her pain, it was agreed that she should have a diagnostic laparoscopy (a surgical procedure to access the inside of the stomach and pelvis through a small hole in the skin). This confirmed the mal-rotation but nothing to establish the pain Mrs C was experiencing.

However, Mrs C remained in severe pain after her operation and because of this and the diagnostic uncertainty, the procedure was carried out again but, once more, no new abnormalities were identified. It was concluded that further surgery would be unlikely to help Mrs C but because of her continuing pain she was admitted to a critical care bed for observation. Mrs C later complained that she had not been provided with appropriate medical treatment.

We obtained independent advice from a consultant general surgeon. We found that in view of Mrs C's chronic abdominal pain, all the investigations and procedures carried out were reasonable and that she had been provided with appropriate medical treatment. For this reason, the complaint was not upheld. However, our investigation also showed that there was no record of the reasoning for a second laparoscopy, discussions with Mrs C, or a copy of her consent. There was no evidence that Mrs C had been given an appropriate explanation for what had happened to her. As a consequence, we made recommendations to the board.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified;
• emphasise to the clinical staff concerned the necessity of following good practice by appropriately recording consent and completing records clearly, accurately and legibly; and
• remind clinical staff of the importance of good communication.