Decision Report 201801280

Summary

Mrs C had surgery to remove her gallbladder at Queen Elizabeth University Hospital. Mrs C was experiencing severe pain following her surgery and it was subsequently discovered that bile was leaking into her abdomen. Mrs C underwent further procedures to resolve the bile leak. Mrs C complained about the medical treatment she received both during and after her surgery.

We took independent advice from a general surgical adviser. We found that the medical care Mrs C received during her surgery was reasonable and did not uphold this aspect of her complaint. However, we did find that there was an unreasonable delay in recognising that Mrs C's symptoms may have been caused by a bile leak. Therefore, we upheld Mrs C's complaint that the board failed to provide reasonable medical treatment after her surgery.

Mrs C also complained about the nursing care she received after her surgery. We took independent advice from a nursing adviser. We found that there was no pain assessment and care plan completed following her surgery. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in recognising her symptoms may have been caused by a bile leak and that there was no nursing pain assessment and care plan completed following her surgeries. 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 possibility of a bile leak should be considered by medical staff in patients who do not recover as expected from laparoscopic cholecystectomy (gallbladder removal).
• Post-operative patients should have their pain assessed, recorded and treated by nursing staff in accordance with relevant guidance.