Decision Report 201911297

Summary

C complained that the board failed to carry out an endoscopic retrograde cholangiopancreatography (ERCP, an imaging test involving a combination of endoscopy and X-rays for examination of the bile ducts and pancreas) procedure reasonably which resulted in a retroperitoneal perforation (a tear in the lining of the abdomen) and post-ERCP pancreatitis (inflammation of the pancreas).

We took independent advice from a consultant gastroenterologist and hepatologist (a physician who specialises in the diagnosis and treatment of disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found that the ERCP was a necessary procedure in C's case, that the perforation and post-ERCP pancreatitis are recognised complications and that appropriate measures were taken to reduce the risk of post-ERCP pancreatitis by administering diclofenac (a non-steroidal anti-inflammatory or NSAID). We did not identify any unreasonable failings regarding C's care and we did not uphold this complaint.

C also complained that they were not informed of the risks of the ERCP (including pancreatitis or duodenal perforation) and that following the ERCP, the tear was not mentioned to C by the consultants and that they were given different stories by them. We took independent advice from a consultant general surgeon. We found that the communication with C regarding the findings of the CT scan (a tear in the lining of the abdomen) was reasonable. We also found that an information booklet was attached to the consent form when it was signed, and that C was appropriately made aware of the risks and complications associated with the procedure. However, we noted that it would be good practice to keep a copy of the information booklet in the medical records and we included this in our feedback for the board. We did not uphold C's complaint regarding the board's communication.