Overview
The complainant (Mrs C) raised a number of concerns that her father-in-law (Mr A) had been subjected unreasonably to a prolonged period of surgery because staff failed to ensure all surgical equipment was available before proceeding, and that a member of nursing staff failed to alert medical staff of a delay in Mr A's being able to move his legs following surgery. Mr A developed a serious complication and became paraplegic.
Specific complaints and conclusions
The complaints which have been investigated are that:
- Lothian NHS Board (the Board)'s delay in sourcing appropriate surgical equipment was unreasonable (upheld); and
- a nurse on duty unreasonably failed to report Mr A's inability to move his legs (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- provide a detailed action plan identifying the changes they have made to ensure a surgical safety checklist is completed by the surgical team in line with World Health Organisation guidelines;
- confirm the action plan also ensures that relevant guidance on consent is followed in relation to obtaining consent for surgical procedures;
- bring the failures in record-keeping to the attention of relevant staff and carry out regular audits to ensure compliance with guidelines;
- provide evidence that all relevant monitoring charts etc are in place for patients who receive an epidural to document normal return of motor function including a clear outline of actions to be taken if motor function has not returned with an expected timeframe;
- ensure that the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs;
- ensure protocols are in place which comply with Royal College of Anaesthetists guidelines on management of epidurals and demonstrate to the Ombudsman that they have been widely disseminated to and utilised by relevant staff; and
- apologise to Mrs C for the failures identified.
The Board have accepted the recommendations and will act on them accordingly.