Overview
Mr C was admitted to the Western General Hospital, Edinburgh, after suffering a brain haemorrhage. On the following day, during the Consultant Neuroradiologist's attempt to clot the blood vessels, the catheter ruptured and glue escaped which caused Mr C to have a stroke.
Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the cause of the rupture was that the syringe containing the glue was pushed too hard, causing too much pressure on the catheter (not upheld);
(b) the risk of the catheter breaking and the risk associated with the use of that particular catheter were not disclosed to Mr C (partially upheld);
(c) Mr C was not informed of alternative treatments available to him (upheld);
(d) Mr C was not allowed a cooling off period to make a decision about treatment (upheld);
(e) Mr C's consent to the procedure was inadequately documented (upheld);
(f) the incident was not properly recorded or investigated (not upheld);
(g) the explanation of what had happened given to Mr C and his wife was inadequate (no finding); and
(h) Lothian NHS Board (the Board) whitewashed the incident (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
(i) provide her with details of the outcome of their review of their current consent policy, taking into account '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) advise her of the outcome of their review of their Incident/Near Miss Reporting and Investigation procedure;
(iii) take steps to ensure that where explanations are given in situations such as this they are properly recorded; and
(iv) apologise to Mr C for the shortcomings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.