Overview
The complainant (Mr C) had an AVF (arteriovenous fistula) in his spine. When the Consultant Neuroradiologist clotted the blood vessels, some glue (embolic fluid) escaped into the central draining vein of the spinal cord which became blocked. Mr C complained that his symptoms were worse after the procedure.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Mr C was given insufficient information to allow him to make an informed choice of treatment; (upheld) and
- (b) the procedure was not adequately explained and he was not appropriately warned about possible complications (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review their current protocols for consent and recording of consent in line with 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive on 16 June 2006 especially for neurosurgical and radiological interventions;
- (ii) include details of procedures, alternatives and possible complications in leaflets and that they are given to patients as soon as the diagnosis is made;
- (iii) develop standard letters to be used until the leaflets are available;
- (iv) ensure that the fact that the relevant leaflet has been given to the patient is recorded in the patient's notes;
- (v) include information about embolisation and the possibility of complication occurring in the appropriate leaflet;
- (vi) ensure that Handbooks for Doctors and protocols on consent include detail on when, where and how to obtain informed consent; and
- (vii) apologise to Mr C for the failings in giving him information.
The Board have accepted the recommendations and will act on them accordingly.