Mrs A complained about the treatment she received from Aneurin Bevan University Health Board between February 2019 and March 2020. Specifically, Mrs A complained that a specialist scan did not identify a tumour in her uterus. She was unhappy that treatment options, including a possible hysterectomy, were not fully considered and discussed with her prior to her surgery and felt that if they had been she might not have needed 2 surgeries. Ms A complained that the Consultant should have obtained her consent for a hysterectomy before her first surgery.
The Ombudsman found that the scans were reported accurately, and it is not always possible to diagnose the origin of a large mass without surgery. He therefore did not uphold this element of Mrs A’s complaint. He found that there was no record of a conversation the Consultant had with Mrs A discussing her choices for treatment, including any possible additional dangers. There were also some elements of the medical record keeping that were inaccurate or unclear. He therefore upheld this element of the complaint. While the Ombudsman could not definitively say that Mrs A would not have needed 2 surgeries, he found that there was enough evidence that a hysterectomy may have been needed that it would have been appropriate for the Consultant to have discussed this with her as a possibility. He therefore upheld this element of her complaint.
The Health Board agreed to, within 1 month of the Ombudsman’s report, apologise to Mrs A for the failings identified and to provide her with a redress payment of £500 in acknowledgment of the injustice caused. It also agreed to remind relevant staff that important discussions with patients must be documented in the records and ideally followed up in a summary letter, to provide relevant staff involved with appropriate guidance in relation to medical consent, and for staff to discuss the findings of the report at their next meeting with their supervisor.