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Case ref:201507471
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Date:January 2017
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that during a surgical procedure at Aberdeen Royal Infirmary to address a condition affecting her spine, Ms A's spinal-cord was injured which led to a significant deterioration of her condition. Ms C complained that staff failed to investigate her new symptoms following the procedure and that they failed to recognise that they were a result of an injury from the surgery.
We took independent medical advice from a specialist in neurosurgery. We found that while the evidence indicated the operation itself was carried out to a reasonable standard and that the cord injury Ms A suffered from was a recognised complication (and one which she had been made aware of prior to the operation), there were shortcomings. Firstly, there was no evidence that clinicians had discussed all treatment options with Ms A during the consent process. Secondly, clinicians unreasonably failed to investigate Ms A's new symptoms before discharge home. Therefore, we upheld Ms C's complaint.
Recommendations
We recommended that the board:
- take steps to ensure clinicians discuss all relevant treatment options with patients during the consent process and document this;
- bring the failings identified in this investigation to the attention of relevant staff; and
- apologise for the failings identified in this investigation.