Summary
Mr A, who was suffering from lung cancer, had an operation at Aberdeen Royal Infirmary to remove his lung. During the operation, Mr A suffered from hypoxia (a deprivation of oxygen). He was transferred to intensive care but did not regain consciousness and died one week later. Mr A's daughter (Miss C) complained about the care and treatment provided to her father.
In investigating, I took independent medical advice from a consultant anaesthetist, as well as considering the board's own investigation of the complaint.
Miss C complained that the consultant anaesthetist failed to provide a reasonable level of care to Mr A prior to and during his surgery. The adviser said that surgery should not have proceeded when it became apparent there was a problem with monitoring carbon dioxide levels in Mr A's blood, and that it was concerning that the consultant anaesthetist had needed advice on methods to maintain blood oxygen levels and treat hypoxia. The adviser also noted that the board's own investigation had acknowledged shortcomings in the communication between the surgeon and the consultant anaesthetist during surgery, and that the consultant anaesthetist had not been assertive enough in their decision-making. I considered that the performance of the consultant anaesthetist fell below the reasonable level of care from a specialist doctor who has achieved consultant grade.
Miss C also complained that her father's suitability for surgery was not appropriately assessed. The adviser said that the tests used for Mr A were generally acknowledged to have limitations and other tests should have been considered which may have prompted more investigation ahead of surgery. The board said that their investigations found no problems with Mr A's pre-operative assessment. I found this to be inaccurate and I was critical of the board for failing to identify that the assessment could have been more robust and to act upon this accordingly. I also found that the failings in the
pre-operative assessment meant that neither Mr A nor his family were able to have an informed discussion about the risks of surgery.
The board acknowledged that there were significant failures in their post-operative communication with the family. It was obvious to staff how unwell Mr A was after his operation, but despite this, it was not until around 36 hours later that someone from the surgical team properly discussed matters with the family. This was the most distressing part of this case. All other issues relate to technical problems, and the difficulties of high risk surgery, but this issue relates to the basics of human kindness and interaction with a family in distress. This contributed significantly to a breakdown in trust between Mr A's family and some medical staff. Although the board recognised that the communication was inadequate, I was not convinced that they have taken sufficient action to ensure this does not happen again.
I upheld all of Miss C's complaints and made several recommendations.
Redress and recommendations
The Ombudsman recommends that the Board:
- provide evidence of the actions taken by the consultant anaesthetist to improve their non-technical skills and their subsequent appraisals;
- provide evidence that the consultant anaesthetist has continued to practice without significant subsequent complaints or concerns being raised;
- provide evidence that the consultant anaesthetist has revalidated with the General Medical Council, if this has been achieved as part of the five year cycle since this operation;
- review its pre-operative assessment procedure for lung cancer surgery, to ensure that cardiopulmonary exercise tests and echocardiograms are included for appropriate patients;
- review their lung cancer pre-operative assessment procedures to ensure FEV1 and the Diffusing capacity of the lung for Carbon Monoxide DLCO are calculated prior to surgery in order that post-operative lung function is taken into account;
- review their consent procedure for lung cancer surgery to ensure that it informs the patient what level of risk the operation will incur for them;
- review their procedures to include a requirement for a member of the surgical or anaesthetic team to speak to either the patient or their family at the first available opportunity following an adverse incident that requires admission to Intensive Care Unit;
- review the findings of the Anaesthetic Department Morbidity and Mortality meeting to identify if, and why medical staff declined to support the consultant anaesthetist in his meeting with the family; and
- remind staff that notes are taken of any meetings with family or patients following adverse events.