Decision Report 201500915

Summary

Miss C decided to proceed with a surgical procedure (to divert the normal flow of urine from the kidneys and ureters into a specially created stoma) to address urine incontinence when other procedures had failed. As a result of the operation, which was performed at the Southern General Hospital, Miss C said she suffered from urinary infections and altered acid-based metabolism (tendency for the blood to become more acidic than normal that required medication) and that she had not been informed of any possible side effects or complications of the procedure beforehand.

We took independent advice from a medical adviser who specialises in urological surgery. We found that while it was documented that medical staff had several discussions with Miss C about the procedure, they failed to document the details of the consent discussions and it was not possible to determine if the risks were discussed with Miss C and understood by her before the operation. Therefore, we were not satisfied that Miss C was fully informed of the risks and in a position to give informed consent.

Recommendations

We recommended that the board:

• review the consent form to ensure that discussions between patients and clinicians about possible risks and complications are clearly recorded;
• bring the failings in record-keeping to the attention of relevant staff;
• consider the adviser's comments in relation to the use of information leaflets; and
• apologise for the failings this investigation identified.