Decision Report 202206021

Summary

C complained about the care and treatment that they received from the board. C said that following gynaecological surgery, they were left with side effects including recurrent pain and the need for further treatment.

C complained that the board failed to provide them with adequate care and treatment in relation to the operation. The board did not identify any failings in C’s care, but did apologise for communication failings relating to the operation. They said that C had experienced a rare complication, but that this had been recognised and treated appropriately.

We took independent advice from a consultant gynaecologist. We found that C’s care and treatment during and after their operation was reasonable and noted that the complication that occurred was swiftly identified and managed. However, we also found that prior to their operation, C was not provided with adequate information about other possible treatment options, including a lack of discussion about the surgery. We also found that the surgical consent process was inadequate.

The board accepted that discussions relating to informed consent and counselling to support patient decisions should be fully documented, and that this had not occurred in C’s case. The board also acknowledged the importance of discussing and documenting all potential post-operative complications with the patient, so that the patient has informed choice when agreeing to a management plan.

We found that there were aspects of C’s care and treatment prior to their operation that fell below a reasonable standard. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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.