Decision Report 201602880

Summary

Mrs C underwent a hip-replacement operation at Victoria Hospital. During the operation, a suture (a stitch used to close a cut or wound) used to repair the muscles at the back of her hip caught the edge of her sciatic nerve (a nerve in the lower back area). Mrs C said that she had not been told when she consented to the operation that this was a potential risk and that it should not have occurred. Mrs C also raised concerns about the time it took medical staff to find out what happened. It was not until three days after the operation that medical staff recognised that Mrs C had sciatic nerve palsy (foot drop and numbness) and she underwent a further operation six days after the first operation.

We took independent advice from a medical adviser who specialises in surgery. We found failings in the consent process which meant that Mrs C was not in a position to give her informed consent for the procedure. We considered that Mrs C should have been warned of the potential adverse outcome in clear terms and language, even though the risk of permanent nerve damage was very rare. We also found the time it took to identify the sciatic nerve palsy and escalate it to the surgeon to be unreasonable. We therefore upheld Mrs C's complaint.

However, in relation to the standard of operation and surgical error, while we accepted this was a significant failing which had an adverse outcome, our view was that it was not evidence of poor practice or of an unreasonable failing in the surgical care provided.

Recommendations

We recommended that the board:

• review the consent process and related documentation to ensure clinicians properly obtain (and document) consent for procedures;
• bring the failings to the attention of relevant staff and ensure the failings are raised as part of their annual appraisal;
• investigate why the finding of sciatic nerve palsy was not escalated and inform us of the findings; and
• apologise to Mrs C for the failures this investigation identified.