Decision Report 202404687

Summary

C complained about the care and treatment provided by the board in relation to excision of a right sided neck lesion.

C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly).

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment in relation to excision of their right-sided neck lesion. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Structures involved in benign neck lesions should be carefully considered, and risks and consequences of removal of benign neck lesions should be clearly explained to patients prior to surgery.

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.