Decision Report 201701469

Summary

Mr C, who works for an advocacy and support agency, complained on behalf of his client (Ms A) about the care and treatment she received at Royal Alexandria Hospital. Specifically, the complaint was about a procedure in which Ms A was given a femoral line (a tube placed by needle into a large vein near the groin) for pain relief. Mr C complained that Ms A was not given any warning or explanation before the procedure. Mr C also complained that it was not carried out properly, as Ms A found it extremely painful.

We took independent advice from a consultant in acute medicine. We found that Ms A should have been given alternative pain relief while medical staff prepared to insert the femoral line. We noted that Ms A's consent for the procedure was not properly obtained and/or documented. Finally, we found that the board had a checklist for carrying out this type of procedure but as it was not used, it was unclear if the procedure was carried out appropriately. Therefore, we considered that the board failed to provide Ms A with reasonable care and treatment and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms A for not giving her appropriate pain relief, for failing to obtain and/or document her consent appropriately, and for failing to document the procedure reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Adequate pain relief should be given to all patients.
• Information given verbally to a patient about a procedure should be documented (including the rationale for the procedure, any alternatives, the risks involved and what the procedure will entail), along with the outcome of the consent discussion.
• Femoral lines should be inserted using the appropriate technique, equipment and anaesthetic, which can be ensured by using the central line checklist.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.