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Case ref:202001145
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Date:May 2021
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Body:Highland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
C was referred to a consultant obstetrician and gynaecologist (specialises in the medicine of the female genital tract and its disorders) regarding a skin lesion they had on their vulva. At the first appointment, the consultant removed the lesion under local anaesthetic. C complained to the board that the consultant decided to remove the lesion without properly examining it, that proper anaesthesia was not applied, and the consultant and nurse demonstrated a lack of preparedness.
The board provided assurances that the consultant did examine the lesion and proceeded with the procedure after discussing the options with C. Additional anaesthesia was applied when C said they could feel the incision. The board also explained that equipment had to be retrieved from the theatre.
We took independent clinical advice and reviewed the medical records. We found that the consultant failed to offer a third treatment option which was to have a smaller biopsy taken for the purpose of making a formal diagnosis and arranging a full excision at a later date. This may or may not have been the best choice, however it would have allowed C to make a more informed decision. There was no evidence to suggest C was not examined properly and we noted the consultant did apply further anaesthesia when C reported feeling pain. Overall, we concluded the General Medical Council principles of decision-making and consent were not fully met and as such the care and treatment provided was unreasonable. We upheld the complaint.
Recommendations
What we said should change to put things right in future:
- All procedures should be carried out following full discussion and informed consent.
- The board should consider using leaflets to supplement the verbal information given to the patient at the time of biopsy with clear instruction on what to expect and how to obtain advice after going home.
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.