C complained about the standard of care and treatment provided to them in relation to a hysterectomy they underwent in January 2020, which resulted in damage to their bowel requiring additional, emergency surgery. In addition to concerns regarding the procedure itself, C also complained that the Board had failed to provide reasonable ongoing care, before, between, and after the surgeries in question.
On investigation, we sought independent clinical advice from an experienced consultant gynaecologist. The advice we received, and which we accepted, was that there were a number of unreasonable failures in the care and treatment provided. Particular key points from our findings were that:
- the damage caused to C's bowel during surgery should have been identified at the time;
- the Board failed to inform C of the complication in a timely manner; and
- the Board failed to subsequently investigate how the injury occurred and the overall conduct of the procedure in a reasonable manner, or apply their duty of candour appropriately.
As a result of these failures, we upheld both of C's complaints.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
(a) |
The Board failed to carry out the operation in a reasonable manner, with damage occurring which was not identified during the operation, that the operation was carried out by a trainee doctor and this was not openly referred to in the complaint response. |
Apologise to C for the care provided by the Board, acknowledging the impact the bowel injury had on C.
|
A copy of the letter of apology which should meet the standards of the SPSO guidance accessible here: https://www.spso.org.uk/meaningful-apologies. By: 1 month of publication of report |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
(a) |
The Board failed to carry out the operation in a reasonable manner. |
A Significant Adverse Event Review (SAER) is carried out which includes review of the pre-operative investigations, the decision to undertake the procedure, the missed complication during the operation, a trainee conducting the operation, senior input during and after the operation, the aftercare, investigations postoperation and support given to the clinicians concerned in relation to the event, in particular to trainee and junior doctors.
|
Evidence a SAER has been completed. By: 6 months of publication of report |
| (a) | The Board failed to inform C of the complication in a timely manner. | Complainants should be informed candidly, openly and honestly when a complication occurs during a procedure, including explaining what happened and what action the Board have taken (or intend to take). |
A review of how surgical complications are communicated with patients and consideration for a standard operation procedure for such instances. By: 3 months of publication of report |
We are asking the Board to improve their complaints handling:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
(a) |
The response to C’s complaint failed to adequately investigate how the injury occurred, the overall conduct of the procedure and learning from the event. |
Complaint responses are open and candid as to what happened and identify learning and what action will be taken in response.
|
Evidence that the findings of my investigation have been fed back to the staff involved, in a supportive manner, for reflection and learning. By: 2 months of publication of report |
| (a) and (b) | The Board failed to identify through their own investigation the need for a SAER. This includes why this incident was not reported/consideration given to a SAER at the time, and why duty of candour wasn’t applied. The complaint investigation did not consider these omissions and prompt a robust investigation into the incident and candid explanation as to what happened. | Where an incident occurs measures are in place to consider whether further investigation is required and providing open and honest communication with a patient. |
Evidence a review of the reporting processes has been undertaken and whether further action is required to reduce the likelihood of a recurrence. By: 3 months of publication of report |