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Case ref:201700231
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Date:June 2018
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Body:Lothian NHS Board - Acute Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C complained about the care and treatment provided to her by the board. She complained that, when she suffered a slipped disc in her back, she was not given appropriate neurosurgical treatment during two periods of care. Ms C also complained that she was later not provided with reasonable treatment by the department for infectious diseases, cardiology, or rheumatology.
We took advice from a neurosurgeon, a consultant in infectious diseases, a cardiologist and a rheumatologist. We found that, whilst overall the neurosurgical care given to Ms C was reasonable, there was a failure to properly document an appointment; that there was no evidence that the likely outcome of surgery was discussed with Ms C; and that there was a delay in follow-up after Ms C underwent surgery. We upheld this aspect of Ms C's complaint.
We found that the care and treatment provided by the department for infectious diseases, cardiology, and rheumatology was of a reasonable standard and we did not uphold this aspect of Ms C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Ms C for the documentation of the neurosurgical appointment falling short of the standard expected; for the lack of evidence that that the likely outcome of surgery was discussed with Ms C as part of the consent process; and for the unreasonable delay between surgery and Ms C's follow-up appointment. 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:
- Documentation of appointments should be in line with General Medical Council guidance. The likely outcome of surgery should be discussed and documented as part of the consent process. Follow-up after surgery should be carried out in a timely manner.
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.