Decision Report 201606269

Summary

Ms C complained to us that she had been given morphine both during and after an operation at the Royal Alexandra Hospital, despite refusing consent for this to be used because she was allergic to it. The board had disputed that Ms C had refused consent. They told us that the anaesthetist had explained to Ms C before the operation that she had a sensitivity to morphine, but was not allergic to it. They said that they also told Ms C that it would be almost impossible to give a general anaesthetic for an operation of this nature without the use of morphine or a derivative.

We took independent advice from a consultant in anaesthesia and intensive care medicine. We found that the anaesthetic technique used by the anaesthetist was appropriate for the procedure Ms C had, even with the risk of side effects. However, given Ms C's concerns about morphine, we found that there should have been an informed discussion about the risks and benefits, which should have been documented. The anaesthetist failed to adequately document such a discussion. Given the importance of this in relation to whether morphine should have been used, we upheld this aspect of Ms C's complaint.

Ms C also complained that the anaesthetist had failed to consider alternative anaesthetic for the operation. We found that the anaesthetist had acted reasonably by putting measures in place to treat any complications during the operation and by ensuring that anti-sickness drugs were available. However, we also upheld this aspect of the complaint, as the anaesthetist had failed to document any discussion with Ms C about alternative anaesthetic for the operation, in line with the relevant guidance.

Ms C complained that the board had lost images taken during the surgery. In their response to our enquiries, the board said that they had been unable to locate the images referred to and apologised for this. We, therefore, also upheld this aspect of the complaint.

Finally, Ms C complained about the board's handling of her complaint. We found that although there had been a short delay in responding to her complaint, this delay had not been unreasonable. We did not uphold this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for:
• not adequately documenting any discussion about the risks/benefits of using morphine and any alternatives
• being unable to locate the images taken during the operation.
• The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Discussions about the risks and benefits of using medication that the patients is concerned about, and discussions about any alternatives, should be documented appropriately.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.