Decision Report 201405146

Summary

Mr C complained about his treatment when he was admitted to Dumfries and Galloway Royal Infirmary for bowel surgery. He had been diagnosed with bowel cancer and underwent surgery to remove the right side of his colon. He became unwell following surgery, experiencing severe pain, and a scan three days later revealed a leak in the join in his bowel. He was taken back to theatre the same day for corrective surgery. He complained about the delay in diagnosing the complication arising from the initial surgery. He also raised concerns that the potential for this complication had not been explained to him in advance and that his wife was not informed of the severity of his condition prior to the corrective surgery.

We took independent clinical advice from a consultant colorectal surgeon who advised us that the risk of a leak was recorded on the consent form that Mr C had signed, thus suggesting that it had been discussed with him. It was our adviser's view, however, that the possibility of a leak should have been considered more closely and a scan arranged a day earlier. We, therefore, concluded that there was an avoidable delay in identifying the leak and carrying out the corrective surgery. Our adviser told us that earlier surgery would not have altered the clinical outcome, however, we noted that it would have minimised the distress caused to Mr C and his wife. We upheld the complaint. The board had already accepted that they should have given more information to Mr C's wife regarding his condition. They had apologised for this and discussed it with senior staff. However, they had not accepted that there was a delay in identifying the leak and we recommended that our findings in this regard be fed back to medical staff.

Recommendations

We recommended that the board:

• arrange for the learning from this decision to be discussed by medical staff at a relevant departmental meeting; and
• apologise to Mr C for failing to identify his post-surgical complication earlier.