Decision Report 201605796

Summary

Mr C complained about the care and treatment he received from the board in relation to a urodynamics assessment (a test which uses pressure readings to assess the function of the bladder) carried out at the Queen Elizabeth University Hospital. Although Mr C returned home on the day of the assessment, he later became unwell and was admitted to the hospital for over two weeks. Mr C considered that the urodynamics assessment had not been carried out appropriately and he complained that this resulted in his subsequent symptoms, including haematuria (blood in the urine) and urine retention (the inability to completely empty the bladder). Mr C also complained that, after he had received treatment as an in-patient, his discharge was unreasonably delayed.

After taking independent advice on this case from a consultant urologist, we upheld Mr C's complaint about the urodynamics assessment as we found that there were technical problems with the way that the assessment was carried out. We did not, however, find that these failings had resulted in Mr C's later symptoms. We found that verbal consent had been obtained from Mr C before the procedure, and we made a recommendation to the board that they consider obtaining consent in writing in the future. We made a number of further recommendations on the basis of our findings, including that the board review their patient information leaflet for urodynamics procedures.

Regarding Mr C's discharge, the advice we received was that there had been no unreasonable delay in discharging Mr C from hospital and we did not uphold this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with an apology for the failure to carry out the urodynamics assessment in line with relevant guidance and advise him if any re-assessment is necessary. 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:

• Staff should be aware of the guidance on good urodynamics practice.
• Consideration should be given to introducing a documented informed consent process for urodynamics assessments.
• The patient information sheets should be reviewed and consideration should be given to including reference to urinary retention and haematuria, plus advice on what to do if these symptoms are experienced.

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.