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Case ref:201805252
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Date:July 2019
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about the treatment which he had received at Ninewells Hospital. Mr C said that he had problems with a left-side perianal abscess (a local accumulation of pus that forms next to the anus, causing tenderness and swelling) and that he was taken to theatre for surgery. When Mr C recovered from the surgery he noted that there was a dressing on the right side of the anus and that the abscess on the left side was still present. Staff assured Mr C that the surgery had gone ahead as planned. Mr C attended his GP a few days later and the GP confirmed the abscess on the left side was still present. Mr C felt that the board staff had operated on the wrong side of his anus.
We took independent advice from a colorectal (bowel) surgeon and a consultant radiologist (a specialist in the analysis of images of the body) and found that Mr C's records showed there was some confusion over the position of the abscess. Examination prior to surgery showed the problem area was identified on the left side and although the doctor who conducted the examination was present at the operation, surgery was carried out on the right side. The doctor did not raise their concerns with the operating consultant. We also found that international guidance states that to reduce the possibility of surgery being performed at the wrong site then the planned site should be marked. This did not happen in Mr C's case and although there was an area of concern on the right side, the area complained about by Mr C was on the left side. Therefore, we upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for performing perianal surgery on the wrong side of the anal canal. 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:
- Staff should ensure that prior to surgery the appropriate site is marked to reduce the possibility of carrying out surgery on the wrong site.
- Staff should be reminded that if they feel that surgery is about to be performed at the wrong site that they inform a senior clinician.