Decision report 201004334

Summary
Mrs C was treated for a vaginal prolapse. She underwent surgery to correct the condition but had complications following the procedure which left her with bladder dysfunction. As a result of this, she required a permanent catheter.

Mrs C was initially taught to intermittently self-catheterise. She was uncomfortable with this procedure and found that it had a detrimental impact on her life. She raised her concerns with the board but it was some time before an alternative form of catheterisation was provided. Mrs C complained that avoidable surgical failures resulted in her losing bladder sensation and that the board failed to warn her in advance that her surgery could permanently damage her bladder. She also felt that the board took too long to investigate alternatives to self-catheterisation.

We found that the board did not warn Mrs C of the possibility of permanent bladder damage prior to her surgery. Whilst we were satisfied that the surgery was carried out correctly and the subsequent complications were unavoidable, we considered that there was an unreasonable delay to providing Mrs C with an alternative to self-catheterisation.

Recommendations
We recommended that the board:
• include information about the potential for permanent bladder problems, and any other significant detrimental outcomes, in their pre-operative counselling for vaginal repair surgery;
• draw their staff's attention to the NICE guidance on surgical repair of vaginal wall prolapse using mesh to ensure that patients are provided with full information regarding the risks and benefits of this procedure prior to giving consent; and
• apologise to Mrs C for the issues highlighted.