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Case ref:201801685
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Date:September 2019
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Body:Fife NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C had a modified Brunelli procedure to his wrist (a surgical procedure that can be used to correct instability in the wrist). Mr C complained that the board failed to inform him of the risks of the anaesthetic, particularly of phrenic nerve palsy (loss of the ability to move the diaphragm and to feel the sensations of the chest and upper abdomen).
We took independent advice from a consultant anaesthetist. We found that there was a failure to discuss the common possibility of temporary phrenic nerve injury with Mr C and that Mr C was not provided with any written information about the procedure. We upheld Mr C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for failing to discuss the possibility of temporary phrenic nerve injury with him and for failing to provide any written information in accordance with the Association of Anaesthetists of Great Britain and Ireland guidance (AAGBI). 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:
- Patients undergoing this type of procedure should be informed of the common risks such as possible temporary phrenic nerve injury. Information leaflets should be provided as per guidance from the AAGBI.
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.