Decision Report 201406218

Summary

Mrs C had a hysterectomy (surgery to remove the uterus (womb)) at Aberdeen Royal Infirmary. She was later discharged and made an appointment with her local hospital (which is in another NHS board area) to have her wound clips removed. A short time after the removal of the clips, once Mrs C had returned home, her wound split open and she had to be admitted to hospital for emergency surgery. Mrs C complained to the board that it was unreasonable that her wound had reopened and that the discharge arrangements were not reasonable.

We took independent advice from a medical adviser, who is a consultant gynaecologist. We did not uphold Mrs C's complaint about her wound reopening. The adviser agreed with the board's own view that this is a recognised, but rare, complication of abdominal surgery. We upheld Mrs C's second complaint regarding discharge arrangements. The adviser considered that there was evidence of leakage from the wound prior to Mrs C's discharge which was not acted on appropriately. During their own investigation, the board had identified failings with the information provided to Mrs C when she was discharged from hospital. However, the advice we received found some remaining issues with the discharge advice and the checklist that the board introduced as a result. We made three recommendations in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C, acknowledging the failings our investigation has identified;
• ensure there is feedback to relevant staff on the findings of our investigation; and
• review their checklist and discharge advice for patients who have undergone hysterectomies, in view of the adviser’s comments.