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Case ref:201609706
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Date:September 2017
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained about her transvaginal tape (TVT) surgery not being performed appropriately at St John's Hospital, as she suffered heavy post-operative bleeding. Mrs C also complained that her post-operative bleeding was not treated appropriately at the Royal Infirmary of Edinburgh. In particular, Mrs C complained that she was given painful vaginal packing (an emergency treatment for excessive bleeding of the vagina) before she was referred for surgery to stop the bleeding.
During our investigation we took independent advice from a consultant gynaecologist. We found that Mrs C had suffered a rare but well-recognised complication of surgery, which did not evidence that the TVT surgery was carried out improperly. The adviser considered that Mrs C was given appropriate treatment for her post-operative bleeding as it was reasonable to try conservative management to try to stop the bleeding before referring Mrs C for surgery. We did not uphold the complaint. However, the adviser considered that the consent form should have documented the risks of TVT surgery so we made a recommendation in light of our findings.
Recommendations
What we said should change to put things right in future:
- The risks of surgery discussed with a patient should be documented, in order to reduce the likelihood of a miscommunication or misunderstanding.
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.