Scottish Public Services Ombudsman

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  • Report number:
    201601541
  • Date:
    April 2017
  • Body:
    Ayrshire and Arran NHS Board
  • Sector(s):
    Health
  • Keywords:
    clinical treatment, complaints handling

Summary
Ms C complained on behalf of her son (Mr A) about the care and treatment he received following a road traffic accident. Ms C said Mr A had suffered a serious injury to his arm in the accident, which had required two operations.  Following surgery, Mr A was transferred for a third operation to another NHS board.

Ms C said she was told following the third operation that Mr A's original surgery had not been properly performed and had had to be revised.  She was told that the original surgery had damaged a nerve in Mr A's arm and that he had developed a life-threatening infection.

Following her complaint to the board, Ms C and her son met the board.  Ms C said the board would not explain why Mr A's first operation had been incorrectly carried out.  Ms C also believed that her son's infection had been caused by a failure to clean his wounds correctly and that the board should have identified this sooner.

We took independent medical advice from a consultant orthopaedic surgeon on the standard of care provided to Mr A.  The adviser said that the board's position that Mr A's operations had been properly performed and his nerve left in the correct position was not logical.  Mr A had as a consequence suffered further damage to his nerve.  The adviser noted that Mr A's wounds were heavily contaminated and at high risk of infection.  However, the cleaning of his wounds and provision of antibiotics to prevent infection were carried out to a reasonable standard.  Overall, we found the board had failed to provide Mr A with a reasonable standard of care and treatment.  We were highly critical of board's failure to acknowledge that Mr A's surgery had not been carried out correctly, resulting in damage to the nerve in his arm.

We also found that the board's handling of Ms C's complaint was inadequate as it did not properly acknowledge the failures in care, despite the board being aware of these at the time.  We found that the board had failed to handle Ms C's complaint in an open and transparent manner and failed to address the concerns of the family properly.

Redress and Recommendations
The Ombudsman recommends that the Board:

  • carry out a significant event analysis ensuring that Surgeon 1 reviews the findings of Operation 3; and
  • provide evidence that Surgeon 1 has reflected on the failings identified in this report as part of their appraisal process;
  • review their complaints investigation in light of the comments from the Aviser and provide Ms C with a full explanation for the findings of Operation 3; and
  • review their handling of Ms C's complaint in order to identify areas for improvement and ensure compliance with the 'Can I help you' guidance.
  • apologise unreservedly in writing to Ms C and Mr A for the failings identified in this report.

Download report number 201601541 as a PDF (48.97 KB)

Updated: May 18, 2017