Decision Report 201600936

Summary

Mr C complained to us on behalf of his daughter (Mrs A). Mrs A experienced complications following hysterectomy surgery at Glasgow Royal Infirmary, including an injury to her bladder. Her right ovary and fallopian tube were also removed. Mrs A subsequently developed a vesico-vaginal fistula (an abnormal tract between the bladder and vagina). Mr C complained that the hysterectomy surgery had not been performed appropriately.

We took independent advice on the complaint from a consultant gynaecologist. We found that the hysterectomy surgery provided to Mrs A had been reasonable. The adviser said that whilst the development of a vesico-vaginal fistula was likely to be due to the hysterectomy surgery, there was nothing that suggested the surgery had not be performed to a reasonable standard. Additionally, the adviser considered it reasonable that Mrs A's right ovary and fallopian tube were removed as it had been deemed necessary during the surgery. However, in our investigation we identified some areas of the consent process which did not meet national guidelines. We made a recommendation to the board on this basis.

We also determined that in response to Mr C's complaint, the board had failed to respond to all the issues raised. We therefore recommended that the board take steps to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failure to notify her of all the risks involved in hysterectomy surgery;
• apologise to Mr C for the failure to adequately respond to his complaint;
• feed back the findings of this investigation to the relevant staff and ensure that they review their process for taking consent for hysterectomy surgery to ensure it is in line with national guidance; and
• take steps to ensure that complaint responses address all issues raised by complainants.