Decision Report 201508685

Summary

Mrs C complained about the care and treatment she received at the Royal Infirmary of Edinburgh when she has a hysterectomy (surgical removal of the womb). Mrs C was concerned that the surgery should not have gone ahead given that she had been suffering from a cold and cough a couple of weeks earlier. Mrs C became significantly unwell after surgery and further tests identified that she had internal bleeding and a blood clot. Emergency surgery was carried out and she also developed a chest infection.

We took independent medical advice and found that there was evidence to show that Mrs C was fit for surgery with no evidence of active infection or respiratory problems. We considered that the hysterectomy was performed appropriately and that the problems she experienced after surgery were recognised complications of the surgery, rather than failings in care. Whilst we did not uphold the complaint, we were critical that there was a lack of clear documentation to demonstrate that Mrs C was fully appraised of all the relevant risks and complications associated with hysterectomy. Therefore, we made two recommendations to the board in order to address the matter.

Recommendations

We recommended that the board:

• ensure that the staff involved in Mrs C's consent process reflect on these findings to ensure that all recognised risks of hysterectomy are fully discussed with patients and documented on the consent form prior to surgery; and
• consider providing patients with written information where appropriate in relation to hysterectomy.