Decision Report 201803008

Summary

Mr C complained about the care and treatment he received from Ayr Hospital in relation to surgery he underwent for penile deviation (curvature of the penis). Mr C was dissatisfied with aspects of the medical and nursing care. Following surgery, he developed a haematoma and infection. In addition, the end result of the surgery was unsatisfactory for him.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and a registered nurse.

We found no evidence that the surgery was of an unreasonable standard. However, we found that informed consent for the surgery undertaken was not properly obtained from Mr C, in line with the General Medical Council's (GMC) guidance on consent. We considered that the medical care Mr C received was unreasonable and upheld this aspect of his complaint.

In terms of the nursing care, we identified failings in that there was a lack of record-keeping to show that Mr C's wound was regularly checked and assessed with the appropriate dressings applied. In addition, in terms of his discharge from hospital, there was no evidence to show that Mr C was given information about caring for his wound at home or that he was supplied with sufficient dressings. We considered that these aspects were unreasonable and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain informed consent from him and for the nursing care failings in relation to wound care, record-keeping, and discharge information. 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 GMC guidelines.
• Patients should be provided with appropriate information as part of discharge planning and document that this should be documented.
• Patients should receive appropriate wound dressings in line with the wound dressing formulary.
• Post-operative patients should have their wound checked and this should be recorded on each occasion.

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.