Decision Report 201609377

Summary

Mr C complained on behalf of his partner (Ms A) about the care and treatment Ms A received following an operation to her knee at Borders General Hospital. Ms A had been admitted for a planned day surgery but was kept in overnight for observation. In particular, Mr C complained that the board had failed to exercise proper care and attention to Ms A immediately after her operation, as no doctor or consultant saw her prior to discharge despite Ms A having been admitted overnight. He was also concerned that Ms A was advised to fully weight-bear following the operation.

We took independent advice from a consultant orthopaedic surgeon and a nursing adviser. The consultant orthopaedic surgeon indicated that, while there are a number of published protocols recommending non weight-bearing initially, the surgeon performing the operation was best placed to judge this, and that in this case the surgeon's recommendation to weight-bear was reasonable.

We were concerned about the lack of communication with Ms A during her overnight stay in the hospital, which the board had accepted and had apologised for. The advice we received from the consultant orthopaedic surgeon was that the delay in communicating Ms A's surgery details would not have an adverse impact of her prognosis. However, we considered that it would have been in line with established practice for Ms A to have been seen on a post-operative ward round during her hospital stay.

We also found that a hand-written operation note was inadequate in that it lacked detail, but we noted that Ms A had been managed in line with the post-operative instructions contained in the hand written note. Both the consultant orthopaedic surgeon and the nursing adviser were of the view that the overall the care and treatment Ms A had received had been reasonable. However, given our concerns about the lack of a post-operative ward round, the lack of detail in the hand written operation note and the lack of communication with Ms A, we upheld Mr C's complaint.

Recommendations

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

• A post-operative ward round should be part of routine surgical care.
• Post-operation instructions should contain adequate detail to allow the transfer of information.

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.