Overview
The complainant (Mrs C) complained to Western Isles NHS Board (the Board) that a locum consultant gynaecologist (Consultant 1) had not carried out the operation originally agreed between her and her consultant gynaecologist (Consultant 2). She was further concerned that Consultant 1 incorrectly told her the agreed operation had been carried out; she later discovered it had not been.
Mrs C also complained that she had been given inaccurate information about her post-operative complications.
Specific complaints and conclusions
The complaints which have been investigated are that:
- Consultant 1 unreasonably failed to carry out a full hysterectomy as agreed with Consultant 2 (upheld);
- Consultant 1 provided inaccurate information about the procedure he had carried out (upheld); and
- the Board provided an inadequate explanation concerning the complications which arose during Mrs C's surgery (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- apologise to Mrs C for the failings identified in complaint (a); in particular, that they did not afford her the opportunity to have the operation she had previously agreed with Consultant 2;
- ensure that the comments of the Adviser, in relation to the issue of consent; are brought to the attention of the relevant staff;
- review the procedures for arranging locum surgical cover, so as to ensure that the locum has the requisite surgical skills and expertise;
- apologise to Mrs C for the failing identified in complaint (b), that Consultant 1 provided her with incorrect information about her operation;
- review their current significant adverse event guidance in light of the Adviser's concerns detailed in this report and share the Adviser's comments with the relevant staff; and
- ensure they have a clear policy in place concerning the transfer of patients from one consultant's care to another.
The Board have accepted the recommendations and will act on them accordingly.