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Case ref:201901728
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Date:June 2021
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Some upheld, no recommendations
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Subject:Record keeping
Summary
A few hours after a surgical procedure, C underwent a second operation due to an internal haemorrhage (a loss of blood from a blood vessel that collects inside the body). Following the second operation, C complained to the board about the documenting of their operations, the estimation of their blood loss, communication with their spouse and colleagues, the removal of the patient controlled analgesia (PCA, a method of allowing a person in pain to administer their own pain relief) which was installed following the operations, and that a follow-up appointment was not provided in the timescale they had been advised.
The board's response was that the operations had been reasonably documented, except the detail of one of the units of blood transfused to C, and that the estimation of blood loss and the removal of PCA had been reasonable. The board accepted that they had not communicated with C's spouse and colleagues as C had wished, and that C had not been given realistic information about the likely timescale for a follow-up appointment.
C was dissatisfied with the responses they received and raised their complaints with this office.
We took independent advice from an obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system).
Although the date and time of the transfusion of the second unit of blood to C during their second operation was omitted, we found that, overall, the board reasonably documented events relating to C's operations. We also found that the board's underestimation of C's blood loss was less critical than vigilance of their condition, observations and blood count. We found that the removal of C's PCA was in line with relevant guidance and that it was reasonable that C was not provided with a follow-up appointment within six weeks given the circumstances. We did not uphold these aspects of C's complaint.
In relation to communication, we found that C's wishes for communication with their spouse and colleagues had not been observed. We upheld this aspect of C's complaint. However, we did not make any recommendations given the action already taken by the board.