Decision Report 201304239

Summary

Mr C had an elective arthroscopy procedure (a type of keyhole surgery) on his right knee at Forth Valley Royal Hospital. The surgery took longer than anticipated. Mr C was discharged home the following day but was readmitted with an infection in his knee several days later. He had to undergo two washouts of the knee (a technique that involves flushing the joint with fluid) and was prescribed antibiotics to treat the infection, although Mr C said that hospital staff did not give him several doses of the antibiotics. The board agreed that this had happened. Mr C then complained that the care and treatment he received during and after his knee surgery was unreasonable.

We took independent advice from a consultant in orthopaedic and trauma surgery, who explained that Mr C had suffered a severe complication of a joint infection after surgery, which is a recognised risk but is a rare complication. The adviser said that overall Mr C's care and treatment was appropriate and the failure to provide him with antibiotics on a number of occasions did not significantly alter the eventual outcome of the infection he acquired. Nevertheless, the adviser considered the failure to administer antibiotics was either due to failure by staff to be aware of the potential complications of this, or an indifference to 'getting it right' and was, therefore, a failing by the board in their duty of care to Mr C. We were, therefore, satisfied there was a failure in Mr C's care and treatment.

We noted that a senior charge nurse had apologised to Mr C for the failure to give him antibiotics and that other nursing staff had been spoken to, to ensure that this was addressed. However, we thought that the board should apologise to Mr C as well. The adviser had further commented that although the board's explanation about the duration of Mr C's surgery was reasonable, the operation notes did not mention any particular problems or difficulties. We would have expected the reasons for the length of Mr C's surgery to have been noted, and we made a recommendation about this as well.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to administer antibiotics;
• provide us with evidence of the action they have taken to address the failure to administer antibiotics; and
• ensure that our adviser's comments in relation to the operation notes are brought to the attention of the relevant staff.