Overview
The complainant, Ms C, an advocacy worker complaining on behalf of a woman (Mrs A), raised concerns regarding the care and treatment provided to Mrs A in respect of her bowel operation at the Royal Alexandra Hospital (the Hospital) on 24 February 2003. Mrs A was unhappy with the lack of information provided to her, her family and her general practitioner (the GP), the timing of her discharge, the failure to timeously diagnose an abscess in her bowel and the failure to arrange a follow-up appointment. The specific points of complaint are listed below.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) there was insufficient communication by the surgical team with regard to operative risks, the complications that arose and the information provided to the GP following discharge (upheld);
- (b) following the operation, Mrs A was discharged prematurely from the Hospital (upheld);
- (c) the clinicians involved failed to diagnose an abscess in Mrs A's bowel within a reasonable time-frame (upheld); and
- (d) a follow-up appointment was not arranged after Mrs A was discharged (not upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) consider the way that they currently record episodes of communication. As a minimum, they should remind staff of the importance of recording significant communication episodes between clinical staff and their patients and their carers. These records should include the time and date of such episodes, the parties present, matters discussed and the patient/carer's understanding of the same;
- (ii) consider introducing measures to ensure that any known complications of surgery which occur, and any resultant consequences, are recorded on the discharge sheet and sent to patients' GPs in a timely manner;
- (iii) inform the Ombudsman of any changes that they have made in response to the Scottish Executive Health Department's guidance 'A Good Practice Guide on Consent for Health Professionals in NHSScotland' (June 2006); and
- (iv) consider introducing measures to ensure that biopsy results following local trans-anal surgery are reviewed urgently and any full thickness perforation is specifically recorded in the case notes. When such perforations are recorded and the patient is still in hospital, the Board should take steps to ensure that the patient is not discharged until reviewed by a senior surgeon. When any such results are received after a patient has been discharged, these should be reported immediately to the patient's GP and an urgent review by the surgical team should be arranged.
The Board have accepted the recommendations and will act on them accordingly.