Health

  • Case ref:
    201800823
  • Date:
    January 2019
  • Body:
    A Medical Practice in the Borders NHS Board area
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment provided to his late mother (Miss  A) by the practice. He complained that the decision to initiate end of life care for Miss A was unreasonable and that she should have been moved to a more appropriate facility for active treatment.

We took independent advice from a GP. We found that the decision to commence Miss A on end of life care was reasonable as she was no longer responding to treatment. We further found that it would not have been appropraite to transfer Miss A to a different facility. We did not uphold this aspect of Mr C's complaint.

Mr C also raised concerns about the practice's handling of his complaint, as they had declined to release any information to him due to him not being Miss A's recorded next of kin and them having no information regarding his position to make a complaint. We found that whilst it was not unreasonable for the practice to take this position, it would have been helpful for them to acknowledge Mr C's complaint in a timely manner and seek further information from Mr C regarding Miss A's personal representative. We also found that the practice failed to respond to Mr C within 20 working days and did not signpost him to this office. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for failing to handle his complaint in a reasonable manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

  • Complaints should be handled in line with the model Complaints Handling Procedure.

Related reading

  • Case ref:
    201704980
  • Date:
    January 2019
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the care and treatment that was provided to her at University Hospital Crosshouse for a melanoma in situ (an early stage of skin cancer where the cancer cells are in the top layer of skin) on her face. Mrs C was concerned that the consent process for the procedure to remove the melanoma was inadequate, as she had been unaware that she would be left with a scar far larger than the area of skin removed. Mrs C complained about the procedure that was carried out and considered that the overall handling of her complaint was unreasonable.

We took independent advice from a consultant maxillofacial surgeon (a doctor who specialises in treating diseases and injuries to the mouth, jaws, face and neck). We found that the procedure carried out to remove the melanoma in situ was appropriate for Mrs C and there were no concerns about the standard of the surgery itself. However, we found that the consent process had been inadequate and that the operation note was not sufficiently detailed. Neither of these records included a diagram to aid understanding of the procedure, and there was no evidence that the extent of the wound Mrs C would be left with had been discussed before the surgery. The advice also highlighted that, despite the fact that the melanoma in situ was in a cosmetically sensitive area on Mrs C's face, no photographs were taken prior to initial investigations. We upheld Mrs C's complaint about care and treatment.

In relation to complaints handling, we found that the board had not responded within the 20 working day target and that Mrs C had not been kept timeously updated. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the inadequate consent process, the quality of the operation note and the complaints handling failing identified. 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:

  • There should be effective communication with patients to ensure they have sufficient information to understand their treatment. The consent process should be in line with national guidance on consent.
  • Consideration should be given to photographing all pigmented lesions or lesions of cosmetic significance prior to biopsy.
  • Operation notes should be of an appropriate standard.

In relation to complaints handling, we recommended:

  • Complaints should be handled within the prescribed timescale and where this is not possible, complainants should receive a timeous update.

Related reading

  • Report no:
    201701938
  • Date:
    December 2018
  • Body:
    Grampian NHS Board
  • Sector:
    Health

Summary

Mr C complained on behalf of his late mother (Mrs A) about the care and treatment she received from the Board.  Mr C and his father (Mr B) complained that there was an unreasonable delay diagnosing that Mrs A had bowel cancer.  In relation to an admission at Woodend Hospital towards the end of Mrs A’s life, Mr C complained that the nursing care was unreasonable and that there was an unreasonable delay diagnosing internal bleeding.

We took independent advice from a consultant gastroenterologist, a registered nurse and a consultant geriatrician. 

In relation to Mr C’s complaint about delay in diagnosis of cancer, we found that inadequate investigations were carried out.  We concluded that if the relevant clinical guidance regarding investigations had been followed, then Mrs A’s cancer would have been diagnosed in 2013 rather than 2016.  We noted that a number of failings contributed to the delay, including a failure to review the quality of previous investigations performed. 

We concluded that the failings in the investigation of Mrs A’s bowel symptoms likely had a significant impact on her ability to survive her illness.  In addition to this, we also concluded that it was likely that with correct treatment Mrs A would not have had prolonged and profound anaemia and may not have developed a myocardial infarction.  Finally, we were critical of the Board’s investigation of the complaint and concluded that they had failed to provide a full and accurate response to the family. We upheld this complaint.

Following surgery in Aberdeen Royal Infirmary to remove a tumour in her bowel, Mrs A was transferred to Woodend Hospital for a period of rehabilitation.  Mr C raised a number of concerns about the nursing care Mrs A received at Woodend Hospital.  We found a number of failings in the nursing care Mrs A received during this admission.  We were critical of the monitoring of Mrs A’s condition and found there was no care plan for the management of her diabetes.  Furthermore, there were failings in pressure ulcer management and also in falls prevention.  We also found failings in stoma care, noting there was no care plan or fluid balance monitoring.  Finally, we noted that there was little evidence of family involvement in care planning and limited records of communication.  We concluded that the nursing care was unreasonable and upheld the complaint.

Mr C also complained that there was a delay in diagnosing internal bleeding during the admission to Woodend Hospital.  We found that medical staff reviewed Mrs A’s condition reasonably during the admission and we did not identify an unreasonable delay in the diagnosis.  While we recognised that there were issues with the nursing observations, we did not consider that these impacted on the ability of medical staff to diagnose Mrs A’s condition.  We did not uphold this aspect of Mr C’s complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

Complaint number

What we found

What the organisation should do

Evidence SPSO needs to check that this has happened and the deadline
(a) and (b)

There was an unreasonable delay in diagnosing that Mrs A had cancer.

The nursing care provided to Mrs A during the admission in Woodend Hospital was unreasonable.

The Board did not investigate Mr C’s complaint to a reasonable standard 

Apologise to Mr C and Mr B for:

  • the unreasonable delay in diagnosing that Mrs A had cancer;
  • the failings in nursing care during the admission in Woodend Hospital;
  • the poor quality of the investigation of the complaint.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

A copy or record of the apology.

 

By:  22 January 2019

We are asking the Board to improve the way they do things:

Complaint number

What we found

What should change

Evidence SPSO needs to check that this has happened and deadline
(a)

Mrs A was not offered a repeat colonoscopy after an incomplete colonoscopy was performed in June 2013 

Patients who have had an incomplete colonoscopy should be offered a repeat colonoscopy or another appropriate investigation in line with clinical guidelines

 

 

Evidence that the gastroenterology department have carried out an audit of current colonoscopy practice.  This should include:

  • the proportion of incomplete colonoscopies over the last 12 months and the reasons for this;
  • the outcomes of incomplete colonoscopies, including whether repeat or follow on tests were arranged in line with national guidelines; and
  • in cases where the guidance was not followed regarding follow up tests, the action being taken to address this.

Evidence that the Board have developed a local protocol to ensure that the national guidelines are followed when colonoscopy is incomplete so that appropriate follow-up tests are arranged  

 

By:  16 April 2019
(a)

The documentation of the extent of completion of the colonoscopy was inadequate.  It was unclear how it was established that the hepatic flexure was passed or whether a scope guide was used

Patient records should include details of how the extent of completion of a colonoscopy has been established. 

Where a scope guide is used, this should be documented 

Evidence that the Board have taken action to ensure that the extent of completion of colonoscopies are adequately documented.  (For instance, the Board might summarise documentation standards on a poster in the endoscopy department, or incorporate this into the colonoscopy reporting system)

 

By: 19 March 2019
(a)

The incompleteness of the colonoscopy was not documented in the discharge letter from the admission in June 2013.

There was no evidence of senior input into the discharge letter

All diagnoses, operations and procedures relevant to a patient’s admission should be accurately documented in the discharge documentation. 

Discharge documentation should receive appropriate input or review from senior medical staff, and this should be documented

Evidence that the Board have reviewed the discharge documentation practice in place in the Gastroenterology Department to ensure that senior medical staff have appropriate input into discharge documentation

 

By: 19 March 2019
(a)

The quality of the colonoscopy in June 2013 was not reviewed at subsequent consultations in 2014 and 2015. 

A colonic cause for Mrs A’s iron deficiency anaemia was not ruled out before iron therapy and capsule endoscopy were performed.

The Board failed to investigate the possibility that the endoscopy capsule had been retained

The quality of colonoscopies should be appropriately reviewed and investigated at subsequent consultations.

A colonic cause for iron deficiency anaemia should be excluded before prescribing iron therapy and performing capsule endoscopy.   

Where a patient reports that they have not passed an endoscopy capsule, investigation should be performed where there is a reasonable clinical suspicion of this complication

Evidence that the Gastroenterology Consultants involved in Mrs A’s care have reflected on their practice in relation to the review and investigation of patients at subsequent consultations and in relation to investigating iron deficiency anaemia.

Evidence that the Board have performed quality improvement work (for instance, development of written guidance or protocol) to ensure appropriate investigations are performed to exclude pathology outside the small bowel and to reduce the risk of a retained capsule.  The Board should provide the SPSO with a copy of any guideline or protocol developed

 

By: 16 April 2019
(b)

Completion of NEWS monitoring charts was inconsistent and not in accordance with guidance.

Mrs A had type 2 diabetes but there was no care plan as to how her condition should be monitored

NEWS charts should be completed to accurately reflect the patient’s condition.  Observations of a patient should be completed in line with the planned frequency in the patient’s records.

A care plan should be in place for patients with diabetes and monitoring should be performed in line with this

Evidence that the Board have reviewed the training needs of nursing staff in relation to:

  • completion of NEWS; and
  • diabetes monitoring.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019
(b) The assessment and management of pressure ulcer risk was inconsistent and incomplete

Patients should receive nursing care to prevent and manage pressure ulcers in line with relevant standards[1]

 

Evidence that the Board have reviewed the training needs of nursing staff in relation to the assessment and management of pressure ulcer risk.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019
(b) It was unclear how information was shared when Mrs A transferred between hospitals   

Relevant information about a patient’s care should be transferred with a patient when the patient transfers between hospitals

Evidence that the Board have a clear pathway in place for inter-hospital patient transfers, which details how key information is shared between nurses in both hospitals

 

By: 16 April 2019
(b)

There was no falls prevention care plan in place, despite the risks identified

 Where a patient has been assessed as at risk of falling, a falls prevention care plan should be in place

Evidence that the Board have reviewed the approach to falls care planning in Woodend Hospital to make sure that risks are identified, and care plans are developed in conjunction with patients, and their family/carers as appropriate. 

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned

 

By: 16 April 2019
(b)

The management of Mrs A’s stoma care was not reasonable.  There was no stoma care plan in the records 

There was no fluid intake and output measurement in Woodend Hospital for Mrs A, despite her clinical condition 

Where a patient has a stoma a stoma care plan should be in place

Fluid balance charts should be used to measure a patient’s fluid intake and output

Evidence that the Board have reviewed:

  • how stoma nurses advise and support stoma care for patients to ensure that there is a patient centred care plan which can be adhered to by all nurses;
  • the use of fluid balance charts at Woodend Hospital.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned 

 

By: 16 April 2019
(b) ‘Five Must Dos With Me’ documented do not appear to have informed the care planning.  Mrs A’s family do not appear to have been involved and there are limited records of communication Patients and their family/ significant others should be appropriately involved in care planning

Evidence that the Board have reviewed how the 'Five Must Dos With Me' inform care plans in Woodend Hospital and have reviewed how families and carers are involved and communicated with.

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned 

 

By: 16 April 2019

[1] Since the time of the complaint, the following standards were introduced: Prevention and Management of Pressure Ulcers Standards. Healthcare Improvement Scotland (September 2016)

We are asking The Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(a)

The Board did not

investigate Mr C’s

complaint to an

acceptable

standard

The Board’s complaint handling

monitoring and governance system

should ensure that failings (and good

practice) are identified and learning

from complaints are used to drive

service development and

improvement

Evidence that SPSO's findings on this complaint

have been fed back in a supportive manner to

the staff involved in investigating Mr B’s and Mr

C’s complaints and meeting with the family and

that they have reflected on the findings of this

investigation. (For instance, a copy of a meeting

note or summary of a discussion)

By: 19 February 2019

 

Feedback

Response to SPSO investigation:

Multiple enquiries were needed in order to obtain the records required by SPSO to carry out a full and detailed investigation.  This led to increased work and lengthened the investigation time.  I strongly encourage the Board to review the way evidence and responses are provided to SPSO.  The Board should ensure that all the relevant records are provided to SPSO at the first request.  Where additional enquiries are made by SPSO, the Board should provide the specific information requested and not duplicates of records already provided.

The Board have accepted the recommendations and will act on them accordingly.  We will follow-up on these recommendations.  The Board are asked to inform us of the steps that have been taken to implement these recommendations by the date specified.  We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that the recommendations have been implemented.

Related reading

  • Case ref:
    201800997
  • Date:
    December 2018
  • Body:
    Western Isles NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C, who works for an advice and support agency, complained on behalf of her client (Mr A) about the care and treatment provided to him at Uist and Barra Hospital. Mr A was catheterised (a process that involves inserting a tube to the patient's urethra to allow urine to drain freely from the bladder for collection), and Ms C complained that this was done unnecessarily, and without his consent. She also complained that the record-keeping for this admission was not of an appropriate standard.

We took independent advice from a consultant physician and a nurse. We found that it had been necessary from a medical standpoint to catheterise Mr A. We also found that whilst Mr A's consent was not documented, there is no requirement for this and there was no evidence to suggest that Mr A did not consent to catheterisation. We considered that record-keeping was of a reasonable standard. We did not uphold these aspects of Ms C's complaint.

Ms C also complained that Mr A's initial verbal complaints were not handled appropriately. The board accepted that this was the case and we, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr A for failing to handle his initial verbal complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

  • Verbal complaints should be handled in line with the complaints handling procedure.

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.

Related reading

  • Case ref:
    201802571
  • Date:
    December 2018
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health
  • Outcome:
    Upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained on behalf of his late wife (Mrs A) that an ambulance crew unreasonably failed to take Mrs A to hospital. Mrs A had taken a reaction to medication which had recently been prescribed for her and her blood pressure had dropped to a dangerous level. The crew felt that it was appropriate for Mrs  A to remain at home as she was due to have a visit from a specialist nurse the following day. Mrs A died a short time later.

We took independent advice from a professional adviser. We found that the crew had managed to obtain two blood pressure readings from Mrs A and they were both at critically low levels. We considered that the blood pressure readings should have indicated that Mrs A was critically unwell and required assessment and treatment at the hospital which may have prevented her death. Therefore, we upheld Mr C's complaint.

We did not make any recommendations in this case as the ambulance service have accepted these failings, apologised and taken appropriate actions to prevent future failings.

Related reading

  • Case ref:
    201706372
  • Date:
    December 2018
  • Body:
    NHS 24
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    communication / staff attitude / dignity / confidentiality

Summary

Ms C complained that NHS 24 failed to provide appropriate assistance when she called them to raise concerns that her mother (Mrs A) had been discharged from hospital too early following a suicide attempt. She said that she had not received any advice or assistance and complained that she had only been able to speak to a call handler and not a clinician.

We took independent advice from a practitioner experienced in out-of-hours services. We found that NHS 24's handling of the call had been reasonable. The call handler contacted Mrs A, who had told them that she had been seen by psychiatry that day and had psychiatric follow-up arranged. The call handler also spoke to a senior nurse. We found that the advice provided to Ms C had been appropriate and it had been reasonable to advise her to contact Mrs A's GP practice at that time. We did not uphold the complaint.

Ms C also complained about NHS 24's handling of her complaint. We found that this had been reasonable and did not uphold this aspect of the complaint.

Related reading

  • Case ref:
    201803249
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the treatment which he received when he attended the Western General Hospital for reported left upper abdomen pain. He said he had advised staff that he was allergic to aspirin and penicillin but was prescribed diclofenac medication (pain relief) on discharge. When he returned home, Mr C took two further diclofenac tablets and experienced breathing difficulties. He attended his GP the following day who prescribed alternative pain relief. Given his allergies, he felt that the diclofenac should not have been prescribed.

We took independent medical advice from a consultant. We found that although diclofenac would not normally be prescribed for a patient allergic to aspirin it was not absolutely contraindicated and should be used with caution. We also found that diclofenac was a non-steroidal anti-inflammatory medication (NSAID) and Mr  C had advised the staff that he was able to tolerate some NSAIDs. We noted that Mr C had been given diclofenac whilst in hospital and that it had a good effect on his reported abdomen pain and he was given advice to seek further medical attention should his condition deteriorate following discharge. On balance, we found that it was reasonable for the doctor to have prescribed the diclofenac. We did not uphold Mr C's complaint.

Related reading

  • Case ref:
    201802106
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the lack of treatment which he received at St John's hospital. He had been referred to the mental health service by his GP for an assessment. Mr C complained that the board failed to carry out appropriate mental health assessments. He was also dissatisfied that the board would not arrange a further medical opinion.

We took independent advice from a consultant psychiatrist (a specialist in the diagnoses and treatment of mental illness). We found that Mr C was seen on two occasions by a doctor in training who discussed Mr C with a supervising consultant psychiatrist. There was evidence that thorough assessments were carried out on both occasions which resulted in a reasonable management plan. Mr C was then assessed by another consultant psychiatrist, who again carried out an appropriate assessment in view of Mr C's reported symptoms. The clinicians reasonably concluded that Mr C was not suffering from a diagnosable mental health disorder. We considered the assessments to be reasonable and did not uphold this aspect of Mr C's complaint.

In relation to a further medical opinion, we noted that Mr C had been assessed twice by a trainee doctor, under supervision of a consultant psychiatrist, and also by an additional consultant psychiatrist. Therefore, we found that it was not unreasonable that the board did not offer Mr C a further medical opinion. We did not uphold this aspect of Mr C's complaint.

Related reading

  • Case ref:
    201708720
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    hygiene / cleanliness / infection control

Summary

Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C also complained about the personal care that Mrs A received and the communication from nursing staff.

We took independent advice from a nursing adviser. We found that:

• the number of ward moves that Mrs A experienced was unreasonable in view of her reduced cognitive function and delirium (sudden confusion)

• the board had failed to keep adequate records regarding the risk assessment and decision making for Mrs A's ward moves and how Mrs A and her family were informed of the ward moves

• the board failed to adequately assess and document Mrs A's care needs. In particular there was no care plan in place to cover Mrs A's personal hygiene needs

• a “Getting to Know Me” document was not in use during Mrs A's admission to St John's Hospital.

In light of the above we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs C for the number of ward moves that Mrs A experienced, the failure to keep adequate records regarding Mrs A's ward moves, the failure to adequately assess and document Mrs A's care needs and complete a 'Getting to Know Me' document. 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:

  • The movement of patients with cognitive impairment between wards should be in line with national standards and guidance.
  • The reason for moving patients to another bed, room or ward should be clearly documented and shared with the patient and/or their representative in accordance with Standard 15 of the Care of Older People in Hospital Standards.
  • Nursing assessments and care plan documentation should clearly document the care needs and preferences of patients.
  • The 'Getting to Know Me' document should be completed and used to inform a person-centred care plan.

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.

Related reading

  • Case ref:
    201706209
  • Date:
    December 2018
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained on behalf of his friend (Mrs A) about the care and treatment she received at the Western General Hospital. Mrs A was referred to neurosurgery (the branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) and was found to have signs of wear and tear to the discs in her cervical spine (the soft cushions of tissue between the vertebra), which was causing compression (squeezing) to her spinal cord. A scan showed that this had caused mature damage in one area of her spinal cord.

Mrs A was referred for surgery to prevent her condition from worsening. Specifically, an anterior cervical discectomy and fusion (where disc material is removed to reduce spinal cord compression). After her surgery, Mrs A experienced weakness and reduced mobility. The board carried out a further scan, which found that Mrs A had mature damage in a second area of her spinal cord. Mr C complained that the surgery went wrong and that Mrs A was never told that surgery could make her condition worse.

We took independent medical advice from a consultant neurosurgeon. We found that Mrs A was appropriately referred for surgery, as she had signs and symptoms of spinal cord compression. However, we found that there was insufficient evidence that the risks of surgery, and of not having surgery, were clearly explained to Mrs A in the consent process. We also found that as Mrs A signed the consent form on the morning of the surgery, she was not given a reasonable timeframe to consider the risks listed on it.

We considered that the surgery might have caused Mrs A's new mature spinal cord damage, given the steps involved. However, we also found there were signs that Mrs A's spinal cord compression had worsened in the months before her surgery. Therefore, we were unable to definitely conclude that the surgery had caused her new mature spinal cord damage. Nevertheless, we found that the possibility of this happening and the other risks involved, should have been appropriately explained to Mrs A and documented. In light of that failing, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mrs A for the failings identified in the surgical consent process. 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:

  • The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery, and what is discussed as part of the consent process (including risks and benefits) should be documented.

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.

Related reading

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