Summary
Mr A was referred by his GP to the ear, nose and throat (ENT) clinic at his local hospital (in another NHS board area) in January 2014 with a swelling below his left ear. This was found to be cancerous and Mr A was referred to the board for surgery. The surgery, which resulted in extensive facial disfigurement, was carried out on 11 March 2014 and Mr A was discharged on 27 March 2014.
Mr A's daughter (Mrs C) complained to the board that they failed to explain the extent of Mr A's surgery and the possible impact on him. Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.
The board noted that the process for obtaining consent for complex procedures such as this takes place over multiple visits, with information being given by different medical professionals. This is to ensure that patients fully understand the information being given to them. They said that Mr A appeared to understand the proposed procedure. They also noted that Mr A was found to be competent and, therefore, able to give consent himself. They said that staff always try to involve patients' families with this process though there was no formal obligation to do so. They were sorry that Mr A's family felt they were not adequately involved.
I took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck). My adviser said that, before such a major procedure, it is important that the patient has all the relevant information, and enough time to discuss it with family and friends, to make an informed decision. He confirmed that a family presence during discussions is not a legal necessity but said it would be recommended by most doctors. My adviser also explained that, although Mr A was diagnosed in another NHS board area, it was the board's responsibility to explain the procedure and get consent. He said that there was a lack of evidence in Mr A's medical notes to show that this was done as it should have been.
In addition, my adviser informed me that most patients who have been diagnosed with head and neck cancer will be seen by a head and neck cancer nurse specialist (CNS), who can help reinforce the issues that have been discussed.
I upheld Mrs C's complaint. It is crucial that patients are given enough information about planned procedures to allow them to make an informed decision. They should also be given enough time to make a decision. The advice I have received, which I fully accept, indicates that Mr A should have been seen earlier by the consultant who performed the surgery, preferably in an out-patient setting with his family and the CNS present. There is no evidence of any involvement by the CNS, or of relevant patient information literature having been provided. This may potentially have been provided by the CNS in Mr A's local NHS board area, but I can see no evidence of the board's CNS having taken action to confirm this. There need to be clearer lines of responsibility when a patient is being referred from one health board to another.
Regarding the complaint about the delays in referrals, my adviser noted that records showed that all the relevant referrals were made within a few weeks of Mr A being discharged from hospital. However, this was not done by the time of discharge. This appears to have been as a result of confusion as to which health board was responsible. I consider that the board ought to have taken steps to clarify this and ensure it was specified in the discharge plan, so I also upheld Mrs C's complaint about the support given to Mr A following his discharge.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) reflect on the failings highlighted in this report with a view to improving the process for obtaining informed consent and report back to me with their findings;
- (ii) take steps to ensure that there is more involvement of the CNS in similar future cases and that this involvement is clearly documented;
- (iii) apologise to Mr A and his family for the failings identified in the process for obtaining informed consent;
- (iv) review their process for treating patients referred by other health boards, and discharging them back into their care, in order to ensure that clear lines of responsibility exist; and
- (v) apologise to Mr A and his family for the failings identified in the discharge process.