Decision report 201001270

Summary
Mr C was admitted to the Western General Hospital for an operation to remove a testicular cyst and to undergo a vasectomy. Five months later, he was referred to another consultant and was told that during the operation the original planned surgery had not taken place. They said that the cyst had not been removed but instead he had had a hydrocele repair and vasectomy. (A hydrocele is an abnormal collection of fluid in a sac-like space such as the testicles.) Mr C complained that he was told nothing about the hydrocele problem and that he had to have a further operation to remove the cyst. Our investigation concluded that although Mr C's treatment was appropriate, the reasons for providing the alternative treatment were not adequately documented. Because of this we upheld his complaint about treatment. We also found that the board's handling of Mr C's complaint was inadequate. We did not uphold his complaint that the hydrocele procedure was performed without informed consent as the consent given included authorisation of any justified procedure found to be necessary during surgery. Our medical adviser confirmed that the procedure was justified.

Recommendations
We recommend that Lothian NHS Board:
• share the decision letter with the consultant and remind him of his responsibilities to maintain a standard of record-keeping which is in line with General Medical Council guidance;
• remind staff about the need to adhere to the timescales as set out in the NHS Complaints Procedure and to provide relevant updates; and
• apologise to Mr C for the failings identified in our decision letter.