Decision Report 201508300

Summary

Mr C injured his shoulder at work and was seen by the orthopaedic team at the Royal Alexandra Hospital. It was decided that Mr C would have surgery on his shoulder and he was placed on the waiting list. A date was allocated for his operation and he attended a pre-operative assessment. However, due to an error, a second assessment appointment was also made for him. Mr C did not attend the second pre-operative assessment as he said he was not notified and as a result, his scheduled surgery was cancelled. He was allocated a new date for surgery but this was cancelled on the day due to an urgent trauma case. Mr C complained about these delays, and also about the standard of his surgery and follow-up care.

After taking independent advice from an orthopaedic surgeon, we upheld Mr C's complaint about delay. Although the cancellation of the second surgery was considered reasonable as urgent trauma cases would be prioritised, we found unreasonable failings around the cancellation of the original surgery date. We considered that had these not occurred, Mr C could potentially have had his surgery much earlier. The board acknowledged these errors during our investigation.

We also upheld Mr C's complaint about the standard of the surgery. The advice we received highlighted that while the operation itself had been carried out reasonably, Mr C had been given a steroid injection into his shoulder that was not appropriate.

In relation to Mr C's concerns about the follow-up care he received after his surgery, the advice we received was that this was reasonable and consequently, we did not uphold this part of his complaint.

Recommendations

We recommended that the board:

• apologise for the delay caused by the duplication of pre-operative assessment appointments;
• ensure that a robust system is now in place to prevent the repetition of this type of issue;
• apologise for the increased risk of infection caused by the use of a steroid injection at the time of surgery; and
• review the approach to steroid injections in joint surgery in light of the adviser's comments.