Decision Report 201508584

Summary

Mrs C said her son (Mr A) had bilateral gynaecomastia (swelling of male breast tissue) and was to have surgery at Dumfries and Galloway Royal Infirmary to remove the excess tissue from both breasts. Mrs C complained that on the day of the operation, the board changed the procedure Mr A was to have by operating on one breast instead of both and failed to communicate this to Mr A appropriately. She also said that the operation was not carried out to a reasonable standard and that the board did not reasonably respond to her complaint about the surgery.

We obtained independent advice from a consultant breast surgeon. The adviser said it was unreasonable that the decision to operate on Mr A's right breast only was made immediately pre-operatively. We were also concerned that the board did not obtain Mr A's signed consent for the revised procedure and that Mr A did not appear to have been shown photographs of other patients who had had the procedure carried out by the board or been provided with written information on the procedure for him to consider in advance of surgery. Therefore, we upheld this part of Mrs C's complaint.

The adviser said it was not possible for them to determine whether Mr A's surgery had been carried out to a reasonable standard or whether the decision to change the surgery had been reasonable as there were no photographs of Mr A's chest before and after surgery and no notes of the surgeon's rationale for making this decision. We therefore did not uphold this part of Mrs C's complaint.

The evidence showed that it took the board nearly 11 months to successfully make contact with the surgeon, who had since left their employment, and that when Mrs C first raised issues about Mr A's surgery, the board logged this as a concern rather than a complaint. We upheld this part of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved, including the surgeon, for future learning;
• ensure that in future cases of this type patients are provided with appropriate written and photographic information in advance of surgery and photographic records are made of patients pre- and post-surgery;
• provide Mrs C and Mr A with a written apology for the failings identified;
• provide this office with a copy of their process for ensuring complaints are shared with staff who have left employment with the board;
• remind relevant staff of the need to properly record complaints when they are received; and
• provide Mrs C with a written apology for failing to respond reasonably to her complaint.