Decision Report 201609237

Summary

Mrs C complained about the clinical and nursing care and treatment she received when she was admitted to Victoria Hospital. In particular, that there was an unreasonable delay in surgery being carried out to remove her ovaries and an unreasonable delay in arranging surgery for the repair of an incisional hernia (a type of hernia caused by an incompletely-healed surgical wound). Mrs C also complained that the nursing care and treatment of her wound following surgery was unreasonable.

We took independent advice from a consultant in obstetrics and gynaecology (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts), a consultant general surgeon and a nursing adviser.

In relation to the clinical care and treatment provided to Mrs C, we found that the delay in carrying out surgery to remove Mrs C's ovaries was not unreasonable. However, we were concerned that some of Mrs C's medical records were missing. We did not uphold this aspect of Mrs C's complaint but made a recommendation about the missing medical records.

With regard to arranging surgery for the repair of an incision hernia, we found that the board failed to meet the legal treatment guarantee time, which states that health boards should take all reasonable steps to ensure that patients receive in-patient and day case treatment within 12 weeks of treatment being agreed. We also found that there was no evidence that Mrs C was advised of her options given the failure to meet this guarantee. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care and treatment provided to Mrs C's wound, we found that there was no evidence of failings in care and that the treatment she received was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable delay in arranging surgery for the repair of an incisional hernia. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Records should be kept in accordance with the Scottish Government Records Management: NHS Code of Practice (Scotland).
• The board should inform patients as soon as possible of any inability to meet treatment targets and provide them with information about the options available to them in the circumstances.

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.