Summary
Mr C, who suffered from a hereditary heart condition, had an operation at the Royal Infirmary of Edinburgh to remove a machine implanted in his chest to monitor his heart. The operation was carried out by a trainee doctor. When the trainee doctor encountered difficulties, he was assisted by a more senior trainee doctor. Mr C subsequently required a second operation to revise the scar the first procedure had left on his chest.
In investigating, I took independent medical advice from a consultant cardiologist, as well as considering the board's own investigation of the complaint.
Mr C complained the first operation had not been carried out to an appropriate standard. He said that the experience had been painful and distressing and believed the correct procedures had not been followed. Mr C believed the trainee doctor performing the surgery had not been competent to do so, noting that the time taken to perform the operation meant he required additional anaesthesia, as his initial dose had worn off.
The board said they had thoroughly reviewed Mr C's treatment. The board said the tools for cauterising the wound to stop bleeding post-surgery had not been available. Silk stitches had been used instead, but these may have contributed to the poor healing Mr C experienced. The board said the consultant responsible for supervising the operation was available, but had not been present throughout the operation. The board acknowledged Mr C's experience fell short of what he could have expected.
The adviser said the board had not adequately explored the conflict between the contemporaneous note of the operation and the conclusions reached by the complaint investigation. The operation note stated cauterisation had been used to stop Mr C's bleeding, but as the complaint investigation acknowledged, this could not have been performed as the equipment was not available at the time. The adviser said the operation note's inaccuracy had not been properly explored, nor did the note record the difficulties encountered during the surgery. The adviser said it was unreasonable for a trainee doctor to be allowed to perform the surgery unsupervised, as it was not a straightforward procedure.
The adviser added the board did not address the issue of supervision. Their complaint response gave the impression a consultant had been present at points during the operation. The available evidence showed no consultant had been present at any point, nor had they been aware Mr C's procedure was being carried out by a trainee doctor. The adviser also noted Mr C's consent was not properly obtained and that there were inadequate records of the information provided to him prior to surgery.
I found the board failed to investigate Mr C's complaint thoroughly, although they had accepted the standard of treatment received was unacceptable. I also found they had failed to deal comprehensively with the service failures Mr C experienced. I am critical of these failings, which resulted in a misleading formal response being provided by the Board and a lack of evidence that adequate steps had been taken to prevent a reoccurrence.
Mr C also complained that the effect of the first operation had not been recognised by the board. He had stated to the board that his business had suffered severely whilst he was unable to work and that he had been forced to cease trading. I was critical of the board for failing to address this issue, even though Mr C raised it twice during his complaint. I considered the board had to address the impact on him of the failure to carry out his surgery in a reasonable fashion.
Redress and recommendations
The Ombudsman recommends that the Board:
- provide evidence of the actions taken by Doctor 2 to improve their skills and their subsequent appraisals;
- provide evidence that Doctor 2 has continued to practice without significant subsequent complaints or concerns being raised;
- provide evidence that their policy for the supervision of trainees during surgical procedures has been reviewed;
- review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
- remind all staff of the importance of documenting consent fully and accurately; and
- provide Mr C with a comprehensive and patient centred response to the issues he has raised concerning the impact of the surgeries on his ability to work and his finances.