Decision Report 201707748

Summary

Ms C underwent abdominal surgery at Dumfries and Galloway Royal Infirmary and complained about the way in which it was carried out. Ms C also complained that the follow-up care and treatment was unreasonable.

We took independent advice from a consultant surgeon. We found that the board failed to explain all the recognised risks and complications of the surgery to Ms  C prior to the surgery. We considered that this was not in line with the General Medical Council guidance on consent. We also found that the board were unable to confirm the operating consultant surgeon's experience in this type of surgery. We concluded that there was a lack of evidence to demonstrate that the operating consultant surgeon was appropriately trained, experienced and had conducted a sufficient number of cases to perform the surgery without the direct involvement of a plastic surgeon. Therefore, we upheld this aspect of Ms C's complaint.

In relation to follow-up care and treatment, the board acknowledged and apologised for failings highlighted in their own complaint investigation. They found that Ms C's symptoms and pain were not fully considered in order to identify and prompt the removal of stitches sooner and that communication around this had been unreasonable. Following our investigation, we also found that an urgent GP referral and ultrasound scan should have prompted urgent surgical review. We also noted that there was no planned review following earlier treatment and that there were no post-operative instructions on operation records. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to inform her of all the recognised risks of the surgery and for not involving the appropriate clinicians in her surgery. 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:

• Operation records should be legible and give sufficient detail to enable continuity of care by another doctor as set out in Good Surgical Practice.
• Surgeons should obtain the patient's consent in the pre-operative clinic in accordance with the Royal College of Surgeons' guidance.
• Surgeons should be appropriately trained, experienced and have conducted a sufficient number of cases to perform this type of surgery.