Decision Report 201706209

Summary

Mr C complained on behalf of his friend (Mrs A) about the care and treatment she received at the Western General Hospital. Mrs A was referred to neurosurgery (the branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) and was found to have signs of wear and tear to the discs in her cervical spine (the soft cushions of tissue between the vertebra), which was causing compression (squeezing) to her spinal cord. A scan showed that this had caused mature damage in one area of her spinal cord.

Mrs A was referred for surgery to prevent her condition from worsening. Specifically, an anterior cervical discectomy and fusion (where disc material is removed to reduce spinal cord compression). After her surgery, Mrs A experienced weakness and reduced mobility. The board carried out a further scan, which found that Mrs A had mature damage in a second area of her spinal cord. Mr C complained that the surgery went wrong and that Mrs A was never told that surgery could make her condition worse.

We took independent medical advice from a consultant neurosurgeon. We found that Mrs A was appropriately referred for surgery, as she had signs and symptoms of spinal cord compression. However, we found that there was insufficient evidence that the risks of surgery, and of not having surgery, were clearly explained to Mrs A in the consent process. We also found that as Mrs A signed the consent form on the morning of the surgery, she was not given a reasonable timeframe to consider the risks listed on it.

We considered that the surgery might have caused Mrs A's new mature spinal cord damage, given the steps involved. However, we also found there were signs that Mrs A's spinal cord compression had worsened in the months before her surgery. Therefore, we were unable to definitely conclude that the surgery had caused her new mature spinal cord damage. Nevertheless, we found that the possibility of this happening and the other risks involved, should have been appropriately explained to Mrs A and documented. In light of that failing, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in the surgical consent process. 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:

• The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery, and what is discussed as part of the consent process (including risks and benefits) should be documented.

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.