Decision Report 201302091

Summary

Miss C complained about her care and treatment when she was admitted to St John's Hospital for planned surgery. In particular, Miss C said that she had left hospital with an open wound, and was given inadequate post-discharge advice and care. She also complained about the care and treatment she received after being re-admitted nine days later with a severe wound infection, and said that her wound packing had been removed on the ward without adequate pain relief, and that packing was left in it.

During our investigation, we took independent advice from two of our advisers, one who is a specialist gynaecology consultant and another who is a plastic surgery consultant. The gynaecology adviser said that the operation appeared to have been straightforward but that Miss C was at high risk of infection. He found no evidence that prophylactic antibiotics (drugs that treat bacterial infection, given in advance of a procedure to reduce the risk of infection) had been given to Miss C during surgery, although he accepted that there might have been a reason for not doing so. He also said that she should have been given antibiotic therapy on discharge. However, he said that there was no evidence that she was discharged with an open wound.

After Miss C returned to hospital she had a further surgical procedure. The plastic surgery adviser was satisfied that the initial assessment and surgery were carried out to a high standard. He also indicated that it was routine practice to remove the wound packing on the ward, but noted that Miss C had not been given any additional pain relief for this procedure which can be traumatic and that this should have been considered. He also advised that it was unlikely that the full extent of Miss C's wound was observed during the procedure and that it was likely some of the large gauze swabs used as packing were left in the wound. We were critical of these apparent failures by the board.

We found nothing in Miss C's clinical records to indicate that at her pre-operative assessment she was given the information the board said she should have. There was also nothing to indicate whether it had been explained to Miss C that she was responsible for passing a discharge letter to her GP. We noted, however, that the board said they had already taken steps to remind staff of the importance of providing appropriate information and advice.

Recommendations

We recommended that the Board:

• apologise to Miss C for the inadequate care and treatment we identified, that she was not given adequate information about post-operative care at her pre-operative assessment, and that it was not properly explained to her that she was responsible for passing on the discharge letter to her GP;
• make relevant staff members aware of our adviser's comments and give them an opportunity to reflect on these for their future practice - in particular in relation to consideration of the use of prophylactic antibiotics both during surgery and prior to discharge, and the issue of pain relief and wound observation at dressing change; and
• provide us with evidence of the steps taken to remind staff of the importance of providing appropriate information and advice as stated in the board's response to Miss C's complaint.