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Decision Report 201905950

  • Case ref:
    201905950
  • Date:
    September 2021
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).

We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.

However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.

In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

  • There should be complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
  • There should be records of discussions with patients regarding the potential for morphine to become habit-forming.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: September 22, 2021