Summary
Mrs A complained about the care and treatment she received from the board. Mrs A died before I completed my investigations and so her complaint was taken on by her daughter (Mrs C).
Mrs A attended University Hospital Crosshouse. She was told that she may need a heart valve replacement but that before this could go ahead, she would need to undergo a cardiac angiogram (a type of x-ray used to examine blood vessels), which is an invasive procedure. Mrs A gave consent and underwent an angiogram in a second hospital run by the board. Mrs A said that she experienced pain during the procedure and asked for it to be stopped. The procedure continued but Mrs A did not recover well and while no abnormality was obvious, her condition did not improve. Mrs A's level of consciousness declined and a few days later she was noted to have lost power in her lower limbs. A scan of her spine showed evidence of an ischaemic event (like a stroke) within her spinal cord.
Mrs A was transferred to a third hospital (in a different NHS board), where her scan was reviewed. This showed the appearance of a stroke on the surface of the brain. Mrs A did not recover the use of her lower limbs.
Mrs A complained that she had not been warned of the possible risks associated with an angiogram. She also complained of an unreasonable delay in confirming a stroke and that as a result her treatment was delayed.
The board said that Mrs A had made informed consent for the procedure and recognised that there had been a delay in diagnosis. They added that even if a stroke had been confirmed sooner, it was unlikely there would have been a different outcome regarding surgery or spinal cord recovery.
I took independent advice from a consultant cardiologist and from a consultant neuroradiologist (a specialist in the analysis of injuries of the brain). The advisers found no evidence that all the risks and benefits of an angiogram had been discussed with Mrs A, including that bleeding and vascular damage that could cause a possible stroke or heart attack are a recognised complication. I also found the board's consent forms and printed information to have been inadequate. I established that there was an error in interpreting Mrs A's scan and that her diagnosis had been delayed, although Mrs A's treatment and outcome were likely to have been the same had an earlier diagnosis been made. I therefore upheld the complaint.
Redress and recommendations
The Ombudsman recommends that the Board:
- make a formal apology to Mrs C for their failure to consent Mrs A properly;
- review their consenting procedure and update it in accordance with General Medical Council guidelines. They should demonstrate to me that they have done so;
- review their relevant information booklet/sheet to ensure that they reflect the appropriate guidelines; and
- apologise to Mrs C for the delay in Mrs A's diagnosis.