Decision Report 201704939

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A) that the consent process followed for an above knee amputation of Mrs A's leg was unreasonable. Mrs A had been admitted to Balfour Hospital for treatment of severe chronic leg ulcers and amputation was planned when other options were exhausted.

We took independent advice from a consultant physician. Although we found that Mrs A had been fully aware of the plan for surgery and had discussed this with staff on the ward, we found that the consent form had not been signed until the day of the procedure. We also found that there was a lack of evidence in both the medical records and the consent form to confirm that the risks and benefits of the surgery were appropriately discussed with Mrs A. The advice we received highlighted that this did not follow national guidance on consent and that, while Mrs A's post-operative care was appropriate, her delirium had not been monitored using the appropriate test. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process for her above the knee amputation was unreasonable. 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 taking process, including risks and benefits, should be documented.
• Where appropriate, patients should be tested for post-operative delirium.

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.