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Case ref:201905950
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Date:September 2021
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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
C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).
We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.
However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.
In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. 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:
- There should be complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
- There should be records of discussions with patients regarding the potential for morphine to become habit-forming.
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.