Western Isles health failed an island woman with gynaecological problems after she did not undergo the procedure she thought she was to have.
She was then given misleading or inaccurate reassurances about the surgery.
The patient complained about the botched operation to the Scottish Public Services Ombudsman who has upheld her concerns, finding “serious failures.”
The health board now faces legal proceedings over the incident.
Although the woman had given consent for a particular procedure, her surgeon was unavailable so a locum carried out her operation.
Health board slammed over bungled operation
19 March 2015
The complainant -
On the day of the operation the consultant she had discussed her treatment with was unexpectedly absent from work.
His temporary replacement was a locum who discussed the impending operation with Mrs C the day before her surgery.
The consent form she signed that day referred to the operation as a 'sub-
Four days after the operation, the locum wrongly told her he had removed her ovaries as she expected.
The consultant later told the board said he had given her the wrong information because
he confused her with another patient -
Suffering on-
After she lodged a complaint, the health board said the consultant said Mrs C had told him she did not wish to have her ovaries removed but then she changed her mind in the operating theatre, immediately prior to the surgery operation.
She advised theatre staff who passed on her wishes, the locum said.
The health board later noted that they had contacted staff who were present in theatre when Mrs C had her operation and the following days of Mrs C's admission but none could recall Mrs C changing her mind about the removal of her ovaries or discussing this with the consultant.
The locum said he found the level of adhesion during the operation, caused by scarring from Mrs C's previous surgery, meant it was not safe to remove Mrs C's ovaries, said the board.
The Ombudsman said Mrs C was concerned the locum misled her afterwards, giving her false reassurances that he had carried out the correct surgery.
She officially complained the consultant unreasonably failed to carry out the hysterectomy procedure as agreed, gave her inaccurate information, and the health board did not adequately explain the complications.
The scarring meant she cannot now have further surgery to complete the procedure, and she continues to be in pain, said the Ombudsman.
A gynaecology specialist who provided independent advice to the Ombudsman highlighted concern the locum consultant was unfamiliar with Mrs C's case but was asked to take on at short notice what was going to be a “challenging and complex operation given her clinical history.”
The adviser found nothing in Mrs C’s notes to show that she changed her mind or that the locum decided not to remove her ovaries.
The board’s response to Mrs C’s concerns about the complications also seemed to demonstrate a lack of understanding of what actually happened, indicated the specialist.
He was also concerned the consultant -
The health board failed to take adequate steps to ensure the locum could cover the specific surgery, concluded the adviser.
The Ombudsman upheld all the complaints. He recommends the health board to apologise to Mrs C for the failings.
He stated: “I found serious failings on the part of the locum and the board both before and after the operation.
“I made a number of recommendations, including that the board bring my adviser’s comments to the attention of relevant staff, review their locum cover procedures and significant adverse event guidance, and ensure they have a clear policy for transferring responsibility for care between consultants.”
NHS Western Isles Chief Executive Gordon Jamieson said: “NHS Western Isles would wish to publicly apologise for this patient’s experience, which fell below the standard we would aim for.
“We accept the Ombudsman’s recommendations and have already taken steps to action a number of these.
“NHS Western Isles would point out that the locum involved in this case was a long-
“NHS Western Isles cannot comment further on this matter as it is now subject to legal proceedings.”