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Case ref:201806059
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Date:June 2020
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C complained that the total knee replacement surgery she had undergone had not been carried out appropriately. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). The board were unable to locate the operation note for the surgery. However, we found that the evidence that was available indicated that it was likely there had been a technical error in the operation in that too much bone was resected (removed). However, without the operation note, it was not possible to state this categorically.
We also found that Ms C had been poorly consented for the operation. There was little evidence that she had been informed of the risks of surgery. The risks of ongoing pain, dissatisfaction and the fact that revision might be necessary were not specifically recorded. It was also unreasonable that the operation note was not available. Given this, we upheld this aspect of Ms C's complaint.
Ms C also complained that the board's response to her complaint was unreasonable. We found that the board's response had been inaccurate about who carried out the operation. There was also a delay in responding to the complaint and no evidence that the board agreed revised time limits with Ms C for responding. Therefore, we also upheld this aspect of the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for the failings we have 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:
- Important documents such as operation notes should be securely retained by the board.
- Patients who are being offered total knee replacements should be given adequate information about the risks and possible complications.
In relation to complaints handling, we recommended:
- Where an investigation takes longer than 20 working days, the board should inform the complainant; agree revised time limits; and keep them updated on progress.
- Responses to complaints should be accurate.
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.