Decision Report 202206634

Summary

C complained about the care and treatment that they received from the board. C attended hospital to have their gall bladder removed by laparoscopic cholecystectomy (keyhole surgery). The surgery was abandoned and C did not understand why. C also complained that communication was unreasonable.

The board advised that C had a high body mass index which made the operation challenging. This was explained at C’s first consultation. Prior to the operation C was referred to the high risk clinic and the risks of the operation were fully discussed with an anaesthetist. The surgeon was also appropriately consulted by email. During the operation, C became wheezy and medication was administered to manage this. When C had stabilised, the operation had to be abandoned because the surgeon was unable to visualise the gall bladder and therefore could not safely complete the surgery laparoscopically.

We took independent advice from a consultant general and colorectal surgeon (specialist in conditions of the colon, rectum or anus). We found that the decision making in surgery was appropriate and that the team had made a reasonable effort to explain why the surgery had been abandoned. However, we found that C could have been referred to weight management services when they were first put on the waiting list for surgery and that the high risk clinic was only six days before the operation, which was not enough time for C to fully consider the risks. We also considered that the surgeon should have been at the high risk clinic to discuss and assess the situation with C and that advice should have been sought from a regional specialist bariatric centre prior to proceeding with surgery. Therefore, we upheld both parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not cancelling the operation and not recommending non-surgical options. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for not writing to them directly, for not ensuring that they fully understood the risks of surgery and the importance of the liver reducing diet and for not fully discussing non-surgical options. 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:

• Ensure that all clinicians write directly to patients and use ‘plain English’ in these letters.
• That specialist input is sought from a regional bariatric centre/specialist before deciding whether or not to proceed with surgery for a severely obese patient. (especially if the surgery is for a condition which is not life limiting).
• When a concern is raised by the pre-operative assessment clinic regarding a severely obese patient, there should be multi-disciplinary involvement, including the surgeon in the high risk clinic so that the BRAN methodology can be genuinely utilised, including for the “alternatives” and “doing nothing” options.

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.