14. Mr U says when he came round from his first surgery, his mouth was very dry so he asked the nurse for a glass of water. He says they came over very quickly and turned him from his left shoulder to his right side and his heart started to beat very fast. He says he shouted out 'no' and 'help' and then everything went black and he thought he had died.
15. Mr U says he next remembers coming round and being surrounded by nurses frantically pouring bags of blood into him. He says after this the heart surgeon came in and said they were taking him for a second operation. He says this was an emergency to fix the problems caused by turning him over and not part of the original plan.
16. Later, Mr U had a phone call with the surgeon involved with his second surgery. He says they agreed his experience was not good enough and the nurse turned him over but did not explain why.
17. In its complaint response, the Trust says it does not have a nurse by the name that Mr U remembers. It says the nurse involved at the time does not remember what Mr U describes. The Trust says they remember a sudden change in Mr U’s condition because of blood loss and he was returned to theatre. It says he was not turned on his side and the nurse did not make a mistake.
18. The Trust apologised that its staff remembered things differently and says after general anaesthetic it is common for patients to experience confusion. It says if any errors had been made these would have been reported in the medical records.
19. The Trust says the complications Mr U experienced can happen after surgery and were not because of a mistake or incorrect procedure.
20. We reviewed Mr U’s medical records and they show he signed a consent form the day before his first surgery. The consent form explains unavoidable and known risks involved with this type of surgery and one of them is bleeding. We can see Mr U signed and consented to this risk.
21. Mr U’s medical records show the surgery started at 3.15pm and finished at 7.50pm. There is no evidence in the medical records of him being turned after surgery. The record says ‘no’ to the ‘patient rolled’ question.
22. The medical records for the next day state that massive bleeding happened at 6.30am. The records state Mr U was taken back to theatre at 7.50am for more surgery. He was given blood transfusions and his partner was called. The records show that after this he returned to the ward. The notes from later this date say, ‘rolled as per skin bundle as and when required, patient is also moving on his own’.
23. We listened to the recording of the conversation between Mr U and the surgeon. Mr U and his partner explain how they feel the bleeding was caused by him being turned by the nurse.
24. The surgeon explains he believes the bleed happened because of clips coming off and how a number of things can cause this, including small movements like sneezing. The consultant says he does not know if this happened because of Mr U being turned. He reassured Mr U that the investigation would uncover any mistakes made which the Trust could learn from. They do say they know the named nurse, which we appreciate does not match what the Trust says about there not being a nurse by that name.
25. The Trust says it has no record of a nurse by the name that Mr U remembers. The Trust listed who was there at the time of the surgery. But we are trying to find out if Mr U was turned and if this caused his bleed.
26. The surgeon apologises for Mr U’s experience and explains they want to assure him his complaint will be taken seriously and will be investigated. We asked for the surgeon’s account of this phone call and what message they wanted to give Mr U. They said they tried to explain what had happened at the time of the bleed and second surgery, to listen to his concerns and to suggest a meeting to discuss them.
27. We have considered how Mr U feels this phone call is evidence of the surgeon saying he was turned. We think it was more that they were attempting to put Mr U at ease and give reassurances that the complaint would be investigated. They were not there at the time because they were only involved with the second surgery.
28. We have carefully considered all the evidence and have different accounts of what happened. We are not trying to dismiss Mr U’s account but there is no evidence within the medical records to support what he says.
29. We have not seen anything to suggest the bleed was caused by him being turned. Bleeding is a known risk of the surgery. We cannot say that something went seriously wrong and that is why the bleed happened.
30. We understand this may not be the outcome Mr U hoped for and it is not our intention to cause him any more distress. We hope our explanations go some way to reassure him that his concerns have been taken seriously.