Decision Report 202002047

Summary

C complained about the treatment that they received from the Golden Jubilee National Hospital. C had surgery to address a non-union of the bones in their mid-foot. Just under a year after their surgery, C submitted a complaint to the hospital, noting that the surgery had failed and that they required a second operation due to the non-union of the affected joint in their foot. C said that they accepted that non-union was a known risk of this surgery. However, having reflected on their experience and having discussed their case with another orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system), C believed that the care provided by their consultant was inadequate and may have been a contributing factor in the failure of their surgery.

We took independent advice from a consultant orthopaedic surgeon. We found that, whilst there was some confusing communication as to the type of surgery that C would undergo, the consultant's choice of procedure was reasonable and the reasoning behind it was valid. C's case was not straightforward due to a previous failed fusion surgery. We were satisfied that the clinical treatment provided was reasonable and that the actions of the board's staff did not contribute to the failure of the joint to fuse.

However, we were critical of the board's decision to discharge C before it was clear that their surgery had been successful. Whilst the outcome would not have been any different for C surgically, ongoing monitoring and review would have allowed for potential issues to have been identified sooner and for the clinical team to have had discussions with C regarding the status of their fusion and their ongoing treatment options. Overall, whilst we found that the clinical care and treatment was reasonable, we were critical of C's early discharge and the quality of the communication from the clinical team. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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 Golden Jubilee National Hospital should share this decision with their orthopaedic staff with a view to identifying ways that they can improve the care and treatment provided to future patients.

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.