Decision Report 201405369

Summary

Mrs C had been admitted to Dumfries and Galloway Royal Infirmary for pelvic floor repair, as she had a prolapse of the wall between her vagina and rectum. She said that she was only told that she might need a vaginal hysterectomy (surgery to remove the womb through the vagina) on the morning that the surgery was to be carried out. She then had a vaginal hysterectomy later that day. Mrs C complained about the action taken in relation to consent for the procedure. We took independent advice from one of our medical advisers, who is an experienced consultant gynaecologist. We found that it was unreasonable that Mrs C was only told about the possibility of such a significant procedure on the day of the surgery and that she was given little time to consider this. We considered that Mrs C should have been told about the possibility that she needed a vaginal hysterectomy at an earlier stage, and we upheld this aspect of her complaint.

Mrs C also complained about the procedure that was carried out. Although we had concerns about the consent process and considered that Mrs C should have been told about the possibility of a vaginal hysterectomy earlier, we found that it had been appropriate for this to be carried out.

Mrs C also complained about the pain relief she had received after the operation. We found that the pain relief had been reasonable. Finally, she complained that the standard of medical and nursing record-keeping was unreasonable. Although there were some missing/incorrect dates and times in the documentation, we found that the notes were of an acceptable standard. Consequently, we did not uphold these aspects of her complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to ensure that the possibility of a vaginal hysterectomy is discussed at an early stage with patients who are to undergo pelvic floor repair; and
• issue a written apology to Mrs C for the failure to mention the possibility of a hysterectomy to her at an earlier stage.