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Decision Report 201704460

  • Case ref:
    201704460
  • Date:
    December 2018
  • Body:
    Fife NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the medical care and treatment he received when he attended Queen Margaret Hospital to have biopsies (a procedure to remove tissue or cells for analysis) carried out. In particular, Mr C complained that, despite telling the operating surgeon that he was in extreme pain the biopsy procedure was continued. He also said that during the consent process for the biopsy procedure, he was not advised there was a risk of major bleeding.

We took independent advice from a consultant urological surgeon (a specialist in diseases of the urinary organs in females and the urinary tract and sex organs in males). We found that the operating surgeon should have stopped or acted to address Mr C's discomfort during the biopsy procedure. We were also concerned that, although uncommon, the risk of major bleeding was not explained to Mr C. While we found that the care and treatment Mr C received following the biopsy procedure was reasonable, we were concerned that the level of communication in relation to the discharge letter was unreasonable. Therefore, we upheld Mr  C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for the failings in relation to the decision to continue the biopsy, the consent process and communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

  • Patients who display signs of distress during a procedure should have this acted on in line with guidance and standards.
  • Patients should be appropriately informed of the risks following prostrate biopsies in line with national guidance on consent.

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: December 19, 2018