Decision Report 201702909

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A) at the Queen Elizabeth University Hospital. Mr A had liver cancer and was admitted to hospital to have a procedure to deliver chemotherapy directly into the tumour. This is known as transarterial chemoembolization (TACE). Mr A become unwell following the procedure and died. The cause of death was linked to some of the chemotherapy drug entering the pancreas and part of the bowel, causing them to become damaged. Mrs C complained about the care and treatment Mr A received in relation to this procedure.

We took independent advice from a consultant interventional radiologist (the type of clinician who carries out TACE procedures) and a consultant heptologist (a liver specialist). We found that the treatment Mr A received was reasonable, however, the adviser highlighted concerns that the consent process was inadequate. The complication that Mr A experienced is a rare but recognised risk of the TACE procedure. We found that there was no documentary evidence that the risks of the chemotherapy drug affecting another area of the body or death were appropriately covered during the consent process. Obtaining appropriate informed consent is an important part of a patient's care pathway. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that the consent process did not adequately document the risks of the procedure. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should be appropriately informed of the risks and benefits of transarterial chemoembolization procedures in line with national guidance on consent.

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.