Summary
C complained to the board about surgery they received on a semi-urgent basis. C complained that the surgery had been inadequate and that they had been unable to fully consent to it due to time pressure and a lack of information. C also complained that the board’s subsequent management of their pain medication was unreasonable. In particular, C complained that they had not been informed of the potential for opiate pain relief to become habit-forming. The board responded that the surgery had been performed correctly and that a lengthy consultation had been held with C prior to surgery by the operating consultant neurosurgeon (a surgeon who specialises in surgery on the nervous system, especially the brain and spinal cord).
We took independent advice from a consultant neurosurgeon. We found that the surgery had been performed to a reasonable standard and that the board’s management of C’s pain medication was also reasonable.
However, we identified a lack of records illustrating any discussion with C about the potential benefits, risks or complications of surgery prior to the operation. We also identified a lack of records illustrating any discussion with C regarding the potential for opiates to become habit-forming.
In the absence of such records we were unable to say whether C received appropriate information. Therefore, on balance, we upheld both complaints.
Recommendations
What we asked the organisation to do in this case: Apologise to C that there was no contemporaneous evidence that C was reasonably informed of the potential risks and complications of surgery or of the potential for morphine to become habit-forming. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future: There should be complete records of discussions with patients about the potential risks and complications of surgery prior to surgery.
There should be records of discussions with patients regarding the potential for morphine to become habit-forming.
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.
Related reading
View Decision Report 201905950 as a PDF (27.05 KB) Updated: September 22, 2021