Issue 1 – haemorrhage following surgery
13. When we consider a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened, by looking at NHS standards and guidance, with what did happen. We have done this and do not think there are any indications that something has gone wrong.
14. GMC guidance (paragraph 15) says clinicians must ‘provide a good standard of practice and care’.
15. Miss H explained she began to feel unwell after her surgery and deteriorated quite quickly. She says the clinicians suspected a bleed and the surgeon commented he must have nicked something during the original procedure.
16. The Provider explained haemorrhage is a known complication of surgery and can be more likely to affect some people than others. It felt it made Miss H aware of the risks during its consent process. The surgeon did not recall saying they might have caused the bleeding at the time.
17. The Provider performed hysterectomy surgery on Miss H in the early afternoon. Our adviser reviewed the notes and felt they indicated the procedure was performed as it should have been.
18. We know from Miss H’s account, after waking up, she began to feel progressively worse throughout the day. The notes show the clinicians assessed she was deteriorating, likely due to a bleed, and took her back into surgery around 3 hours after the first surgery.
19. Our adviser commented positively on the quick time in which the Provider identified there was an issue and got Miss H back into surgery. We think this indicates the provider was monitoring and assessing Miss H proactively while she was in recovery.
20. Our adviser reviewed the notes and explained the bleed was noted as being from the colpotomy angle (the angle of the surgical incision into the wall of the vagina). They explained this is a common site of bleeding after hysterectomy surgery and is a risk that presents in 1-4% of surgeries.
21. We can see the consent form signed by Miss H, under ‘Serious occurring risks’ both ‘haemorrhage’ and ‘return to theatre’ are listed alongside the likelihood they would occur. This, alongside our adviser’s opinion, tells us that just because there was a bleed, it does not necessarily mean something went wrong during the surgery.
22. There are conflicting accounts of whether the surgeon said they might have ‘nicked something’ during the initial surgery. There isn’t clear evidence for us to conclusively say whether they told Miss H this.
23. We asked our adviser to comment on whether there was any evidence the surgeon had caused the bleed as detailed in Miss H’s account. They explained if a surgeon had unintentionally cut a vessel, it would have been immediately apparent at the time of the injury due to the bleeding and would have needed to be repaired immediately. On review of the notes, we cannot see any reference of a vessel being cut and repaired.
24. Balancing the evidence, including our adviser’s opinion, it seems bleeding was a risk that unfortunately presented in Miss H’s case. We cannot see any evidence that poor care led to the bleed, and we think the surgeon performed a good standard of care in line with GMC guidance (15).
25. We will not take further action on this point but would like to acknowledge what a frightening experience this must have been for Miss H.
Issue 2 – Infection
26. GMC guidance (17) says clinicians must ensure they have consent before providing treatment.
27. Miss H explains within a few days of her surgery she developed a serious infection. She explains how unwell she was and how this affected her recovery, which took four weeks longer than she anticipated.
28. The Provider explained that infection is an unfortunate risk with all major surgery. It says it advised Miss H of the risk during its consent process.
29. The consent form, signed by Miss H prior to the procedure, lists the ‘Frequent risks’ of her surgery, and includes ‘wound infection’. Our adviser confirmed infection is a recognised risk of surgery.
30. This tells us that unfortunately an infection will occur after some surgeries and we cannot say, just because the risk presented that there was a failing in the care.
31. Our adviser told us the Provider prescribed Miss H with antibiotics which was the right thing to do to minimise this risk of infection.
32. Having reviewed the records, and asked our adviser to do the same, we have not identified any concerns with the care that might have increased the risk of infection.
33. In summary, we think the provider provided a good standard of care in trying to prevent infection and made Miss H aware of the risks and gained consent in line with GMC guidance (15 & 17). We will not take further action on this point.
34. We would like to wish Miss H well in the future and hope our comments and consideration bring her some answers regarding the care she received.