Decision Report 201808781

Summary

Ms C complained about the care and treatment she received from Victoria Hospital. She said that there were delays in receiving appointments and treatment; that she was not properly consented for surgery; that a stent was removed without anaesthetic; and that after surgery she was left with a bulge/hernia that did not receive timely treatment. In responding to the complaint, the board acknowledged that Ms C had incorrectly been sent a letter saying that she was no longer on the waiting list for surgery and incorrectly advising that she would require another GP referral. The board also found that the bulge she was concerned about had not been examined as it should have been; that there were some communication failures; and that an appointment had to be rescheduled twice. The board apologised for these errors.

We took independent advice from a consultant urological surgeon (a specialist in diseases of the urinary organs in females and the urinary tract and sex organs in males). We found a number of failings in terms of it being unclear about; what treatment options had been discussed with Ms C; the implications and risks of the change in surgery; poor record-keeping; the removal of the stent was not clearly explained; and no written advice leaflet provided. Therefore, we concluded that Ms C's care and treatment was of an unreasonable standard and upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• The consent process (and evidence of it) should start earlier than the day of surgery and General Medical Council guidance should be followed.
• Clinicians should keep clear, accurate, and legible records which report the relevant clinical findings, the decisions made, the information given to patients, any drugs or other treatment prescribed and who is making the record and when.
• When available, explanatory leaflets should be used to assist patients in their understanding and decision-making.

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.