Decision Report 201809975

Summary

C agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was incontinence.

The board said that they could not comment on the information provided about the procedure as it was care provided by another board. We found that, while the procedure itself was carried out in another health board area, it was clear from the board's records that the procedure in question was discussed with C at a consultation within Borders NHS board and their agreement to proceed with the procedure was obtained.

We took independent advice from a urology (specialists in the male and female urinary tract, and the male reproductive organs) adviser. We found that the board failed to provide adequate information to C about the planned procedure prior to obtaining their consent. Therefore, we upheld this complaint.

C also complained that the board failed to provide them with reasonable aftercare in that they had to arrange follow-up care independently and had to undergo a further unnecessary test. The board said that C's discharge letter, outlining need for aftercare, was not copied to them by the board who carried out the procedure and acknowledged that C had to arrange follow-up care independently. We found that the board did not receive information about required aftercare from the other board and that the further test was necessary. Therefore, we did not uphold this complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board did not respond to a specific concern raised in C's complaint and as such we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with adequate information about the procedure and its recognised complications prior to obtaining their consent and for failing to handle their complaint reasonably. 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 should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative options; and those discussions should be clearly documented.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

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.