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Case ref:201808494
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Date:March 2021
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Body:Greater Glasgow and Clyde NHS Board - Acute Services 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 about the care and treatment she received at Queen Elizabeth University Hospital. Ms C underwent splenic artery embolization (a procedure that involves inserting a fine tube into the blood vessel that supplies blood to the spleen and deploying a device to treat an aneurysm). A complication occurred and following the procedure it was identified that a fine piece of filament was retained in Ms C's leg. A further procedure was performed the following day and the filament was removed. Ms C experienced significant discomfort during and after the procedure. Ms C remained dissatisfied following receipt of the board's response to her complaint and brought her complaint to us.
We received independent advice from a radiology adviser (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the first procedure was not performed reasonably as there was a failure to identify the retained filament before the procedure ended. We found that the second procedure was performed reasonably and we considered that the board had taken reasonable action to learn from the complication that occurred. Finally, we considered that the consent process was inadequate as it was not clear that Ms C was informed about the possibility of pain as a result of the procedure. We upheld Ms C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for the failings in care and treatment 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:
- Patients should be informed about discomfort and common relatively minor side effects following a procedure as well as more serious complications using simple terms.
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.