Decision Report 201303020

Summary

Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of the operation he was told that he had been moved to last on the theatre list. When he asked why, he was told it was because he previously had methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to some common antibiotics, can cause infection and can be difficult to treat). This caused Mr C some distress. He complained that his history of MRSA had impacted on how his surgery was managed, although he had told staff - both at his pre-operative appointment and on the morning of the operation - that he had been given the all-clear a few years before.

In responding to Mr C's complaint, the board acknowledged that it was unfortunate that he did not receive the information booklet in advance. They also said that there was no requirement to screen day surgery patients for MRSA, and that their infection control policy did not require MRSA-positive patients to be last on the theatre list, as measures were in place to mitigate against cross infection risks. However, they then went on to say that the consultant had placed Mr C last on the list as he had a history of MRSA and there was nothing in his records indicating that he was clear of the infection.

As part of our investigation, we obtained independent advice from one of our medical advisers. Having done so, we upheld the complaint. We noted that the board had failed to provide pre-operative information to Mr C at the right time. We also found that they had deviated from their normal policy without properly explaining the reason for this. Their response to Mr C's complaint had been contradictory, in failing to explain why the consultant had not adhered to their policy.

Recommendations

We recommended that the board:

• bring their infection control policy to the attention of staff and highlight the importance of adhering to this;
• review their process for ensuring patients receive any relevant pre-operative information in a timely manner;
• remind staff who handle complaints of the importance of providing clear and consistent responses; and
• apologise to Mr C for the failures highlighted in our decision.