Decision Report 201508001

Summary

Mr C complained about the care and treatment he received during a number of admissions to Borders General Hospital.

Mr C was concerned that given previous surgery, he should not have been offered endoscopic retrograde cholangiopancreatography (ERCP, a procedure where a flexible tube is passed into the small intestine). Mr C also complained that the ERCP was not carried out in an appropriate manner and led to the need for further surgery and treatment, which were also not carried out in an reasonable manner.

We took independent advice from a consultant general surgeon. The advice we received was that the care and treatment provided to Mr C was appropriate and reasonable. Mr C suffered a number of recognised complications following what the adviser considered was a reasonable decision to offer him ERCP. The advice we received was that the clinical management decisions made in Mr C's care and treatment were in accordance with accepted good practice. We therefore did not uphold these aspects of Mr C's complaint.

Mr C also complained that he was not given appropriate information about what might happen should the drain fail. We found that the medical records did not detail any discussion held with Mr C about alternatives to ERCP and failed to detail what advice was given to Mr C. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• consider reviewing their procedure-specific consent form for ERCP to include a section to record any alternatives to the procedure;
• consider the adviser's comments on the importance of including in the medical records detail of discussions held with patients with regard to treatment options and their potential outcomes and report back to this office on any action taken;
• remind staff of the importance of recording key information given to patients; and
• consider the adviser's comments on the use of a leaflet for patients with information on how to manage surgical drains, including information on what to do if a drain appears blocked and report back to this office on any action taken.