Decision Report 201508487

Summary

Ms C complained that the board failed to provide her with appropriate orthopaedic surgery. She also complained that they did not provide her with appropriate clinical treatment when she reported health problems following the surgery.

Ms C had an initial operation to treat a bunion affecting her right foot. The operation was not successful and she elected to undergo further (revision) surgery. Following this surgery, Ms C's condition appeared to improve. However, over the subsequent years she experienced further problems with her foot, including pain and discomfort. Ms C also felt that this triggered other health problems. During this time, the board attempted to treat these problems with orthotics (supports) and also referred Ms C to their pain management clinic.

Ms C raised concerns about the revision surgery, including that the surgeon had left a bone in her big toe too short. Ms C also said the surgeon did not provide appropriate care when the problems arose with her foot, that they were unresponsive, and did not communicate with her about her situation. The board said that the shortening of the bone in Ms C's foot was inevitable as a result of the two operations, and within reasonable limits. They considered the surgery had been performed appropriately. The board also said they considered the follow-up care was reasonable.

After receiving independent advice from an orthopaedic surgeon, we did not uphold Ms C's complaints. We found that the evidence did not suggest there had been a failure in the operation. We also found that the medical records suggested timely care with appropriate review from the clinicians involved in Ms C's care. We noted the difficulty of judging communication from paper records, but considered that there were no failings evident in respect of this aspect of Ms C's care.

During the course of this investigation, we noted that the board's consent documentation, while appropriate by the standards of the time, would not comply with contemporary practice. We also noted some limitations in record-keeping by the board. We made recommendations to address this.

Recommendations

We recommended that the board:

• remind staff of the importance of adequate record-keeping; and
• review the relevant consent form to ensure it is appropriate.