Drainage surgery
14. Mr O complains he was admitted to hospital on 12 April 2023 after a stroke and had unnecessary surgery on his pre-existing condition hidradenitis suppurativa.
15. Hidradenitis suppurative is a condition of the sweat gland bearing skin which typically is long term with episodes of infection and sometimes abscesses. Mr O says he has been living with the condition since 2019 and the surgery he underwent, involving an incision and drainage, worsened his symptoms. According to Mr O, the procedure could have waited until he recovered from his stroke.
16. The World Journal of Emergency Surgery gives advice on appropriate treatment of complex abscesses. It says complex skin and subcutaneous abscesses (painful, pus-filled lumps under the skin caused by bacterial infection normally near hair follicles or broken skin) are typically well circumscribed (well-defined) and respond to incision and drainage.
17. We can see that shortly after Mr O was admitted with a stroke on 12 April 2023, the Trust identified that his hidradenitis suppurativa had flared up. He was subsequently reviewed by the dermatology team who suspected he had an abscess and he was referred for an ultrasound scan. The scan results, which were discussed at a multidisciplinary meeting on 20 April 2023, confirmed Mr O had an abscess in his right armpit and he was referred to the general surgeons to drain the abscess on 21 April.
18. Our adviser said incision and drainage are the appropriate actions to take when there is an abscess. They also said the timing of the drainage surgery depends on the clinical circumstances but generally, it should be performed as soon as possible to avoid it getting bigger and risking the development of sepsis (a life-threatening emergency where the body’s response to infection damages its own tissues).
19. We can see that prior to surgery, Mr O had been on antibiotics to treat his abscess, and this had not been successful. He had also used an immune suppressant adalimumab, which he did not respond well to. Our adviser said it is common and good practice to drain an abscess surgically because they do not usually improve with antibiotics. According to our adviser, incision and drainage was the appropriate course of treatment for Mr O, in the circumstances.
20. We understand Mr O’s concerns about undergoing surgery so soon after his stroke and his concerns that his symptoms worsened after he had the drainage surgery.
21. Our adviser says it would not have been reasonable for the Trust to await recovery from his stroke before doing the drainage surgery because recovery time from a stroke is unpredictable. Our adviser also explained that the aim of surgery is to reduce the inflammation and remove the source of infection and as previously noted, the Trust needed to act quickly to prevent Mr O’s symptoms from worsening, leading to potentially dangerous consequences for him.
22. Based on the World Journal of Emergency Surgery guidance and the advice we have received we consider it was necessary for Mr O to have the drainage surgery. The records show the Trust carefully considered the best course of action to treat the abscess it had identified during Mr O’s admission and the decision to perform surgery was made by the dermatological team, who were the right team to recommend suitable treatment.
23. We understand that this was already a distressing time for Mr O and his family as his primary reason for admission was a stroke he had suffered on 12 April. The worsening of his hidradenitis suppurative at this time would have undoubtably been worrying for him and for his family to witness.
24. We hope it reassures Mr O to know the Trust’s decision to carry out drainage surgery, when it did, was appropriate and in line with the above guidance. We find no failings in the Trust’s decision to carry out the drainage surgery.
Consent
25. Mr O complains he did not have the mental capacity to consent to the drainage surgery following his stroke and therefore he could not have consented to it.
26. In its response, the Trust acknowledged that Mr O had some difficulties communicating after his stroke. It said as a result of Mr O’s expressive and receptive dysphasia (difficulty with speaking and writing and with understanding spoken and written language) caused by left brain stroke, it is possible he might not have been able to fully understand the risks and benefits of the procedure when they were explained to him. However, it said the anaesthetist and surgical consultant who reviewed him did not raise any concerns about his capacity to consent to the procedure.
27. The Trust explained that the plan for surgery was relayed to Mr O and his family and his verbal consent was obtained. The notes show the procedure was discussed with Mr O and his wife in advance, and he nodded to indicate his understanding.
28. The GMC guidance on decision making and consent states that consent should be proportionate and consultation with relatives is appropriate. In particular it says consent does not always need to be a formal process and clinicians can rely on a patient’s verbal consent, as long as they are satisfied the patient has had the opportunity to consider any relevant information and decided to go ahead.
29. Our adviser says the capacity to give consent is decision specific and in the circumstances of Mr O requiring minor surgery to drain an abscess, it was reasonable to accept his nodding and giving verbal consent as adequate consent. Our adviser said the Trust took a proportionate approach.
30. Our adviser said the Trust could have carried out a formal assessment of Mr O’s capacity before the procedure, such as a mini–Mental State Exam. However, our adviser said that even if an assessment had been carried out and had proven Mr O lacked capacity, it is likely the procedure would still have been performed in Mr O’s best interests. As such, the outcome would have been the same.
31. The records show on 20 April the Trust explained to Mr O that he had more pus under his right armpit which needed to be drained and it was best for the procedure to be done under local anaesthesia. We can also see evidence that the Trust had discussed the details of the drainage procedure with Mr O’s wife. The records indicate Mr O cooperated with the procedure, indicating it was reasonable for the Trust to conclude he had consented to surgery.
32. We appreciate Mr O and his family were concerned about Mr O undergoing surgery, given his health circumstances at the time and the impact it may have had on his capacity to consent. We find the Trust acted in line with GMC’s guidance on decision making and consent in discussing the procedure with Mr O and his wife and obtaining Mr O’s verbal consent before surgery.
Surgical procedure by bedside
33. Mr O says his surgery was carried out inappropriately as it was done openly and by his bedside, in a non-surgical environment. He says his privacy was not respected.
34. The GMC good medical practice guidance says clinicians must make the care of their patients their first concern and promptly provide treatment where necessary. It also says clinicians must respect a patient’s dignity and privacy.
35. The Trust acknowledged operating at Mr O’s bedside did not give him sufficient privacy. It explained Mr O needed surgery and there were no suitable clinic treatment rooms. It said the procedure was carried out by his bedside under local anaesthetic, which it had explained was safer than general anaesthetic.
36. Our adviser said the Trust’s decision to operate by Mr O’s bedside was not ideal for Mr O’s dignity and privacy but the Trust’s reasons for operating by his bedside were reasonable in the circumstances. Our adviser said waiting for a slot in theatre could have taken a number of days, and in the circumstances, it was clinically appropriate to drain the abscess under Mr O’s right armpit on the ward, to relieve the pain he was in and to prevent his condition from worsening.
37. The records show that a full anaesthetic assessment was carried out suggesting that general anaesthetic should be avoided to reduce the risk of worsening his stroke. We can also see the Trust explained to Mr O’s wife that the procedure was going to take place on the ward and it is recorded that she was happy with the procedure to take place.
38. Therefore, unfortunately it was not possible to perform the surgery in a more private environment, and as the surgery was necessary to prevent any further deterioration, we consider it was in line with the above GMC guidance and in Mr O’s best interests for the Trust to perform the surgery promptly.
39. Mr O says he bled profusely during surgery which he found traumatic and having the procedure on the ward meant other patients witnessed it, which added to everyone’s distress.
40. The records show Mr O lost one unit of blood and he required a blood transfusion. This would have been a very upsetting and frightening time for Mr O and his family.
41. Our adviser said it is not possible to conclude that conducting the surgery at Mr O’s bedside increased his risk of bleeding because even if Mr O’s surgery had been conducted in theatre with electrocautery available (surgical technique using electric current to destroy blood vessels to minimise bleeding during surgery) bleeding may have occurred anyway.
42. Our adviser said Mr O’s blood loss was managed appropriately on the ward. The records show that Mr O’s case was discussed with the haematology team and the stroke team to decide what treatment could be given to stop the bleeding. Our adviser said it was appropriate to give him a unit of blood, and the bleeding stopped after pressure was applied.
43. We understand Mr O’s concerns about undergoing surgery by his bedside, especially after losing a significant amount of blood after the procedure. This would have been terrifying for Mr O to witness.
44. We have found that delaying surgery until a treatment room became available would not have been in Mr O’s best interests and may not have prevented the loss of blood he unfortunately suffered. We consider the Trust acted in line with the GMC good medical practice guidance and currently have not identified failings for this part of the complaint.
Risks of surgery
45. Mr O complains the Trust overlooked the concerns he had raised about the risks of surgery, in particular the fact he was on a blood thinning medication, clopidogrel, which increased his risk of bleeding.
46. Clopidogrel is an antiplatelet medication used to reduce the risk of heart attack and stroke by preventing blood clots. It was being prescribed to Mr O as he had recently suffered a stroke.
47. According to the Clopidogrel Handbook there is a risk of major cardiovascular events if clopidogrel is stopped. As such, Mr O would have been at risk of a further stroke if he had stopped taking the medication.
48. Our adviser said while taking clopidogrel increases the risk of bleeding, it was reasonable for the Trust to balance this risk against the risk of Mr O suffering a further stroke.
49. We understand Mr O’s concerns about surgery especially with the added risks associated with continuing his blood thinning medication. We have seen no evidence in the records to suggest that the Trust overlooked Mr O’s concerns about his increased risk of bleeding.
50. We have found that even though clopidogrel increases the risk of bleeding, if Mr O had stopped taking the medication, he would have been at risk of a further stroke. We consider the Trust’s decision to continue Mr O’s blood thinning medication was in line with the Clopidogrel Handbook. We have also explained above why we consider surgery was necessary in the circumstances. We have therefore not identified failings for this part of the complaint.
Doctor consultation
51. Mr O complains the Trust did not consult his consultant dermatologist who had previously advised against surgery.
52. The Trust said it had liaised with Mr O’s consultant and had included him in the decision making before recommending surgery. It clarified that while Mr O’s consultant was against him having surgery, the consultant’s advice specifically related to extensive surgery under general anaesthetic. The Trust explained the incision and drainage procedure Mr O had undergone was not classed as extensive surgery as it was a small surgical procedure under local anaesthetic aimed at improving his symptoms of pain and to speed up his recovery.
53. The records show Mr O’s consultant was involved in discussions concerning his care leading up to his surgery as there are numerous references to liaising with his regular consultant.
54. Our adviser said extensive elective surgery to remove the affected skin would not have been appropriate for Mr O because of his preexisting health issues, but incision and drainage was appropriate for Mr O.
55. Good Medical Practice guidance says clinicians must refer a patient to another practitioner when this serves the patient’s needs.
56. The records show the stroke team referred Mr O’s care to the dermatology team who our adviser said were best placed to recommend appropriate treatment. The dermatology team made an informed decision about Mr O’s care and treatment after viewing the results of an ultrasound and our adviser said it made an appropriate decision to refer Mr O to the surgical team for incision and drainage.
57. Therefore, we consider the Trust acted in line with the above GMC guidance and spoke to Mr O’s consultant and referred his care to the Trust’s dermatology and surgical teams when this served Mr O’s needs.
58. We can see that Mr O’s consultant was adequately involved in discussions about his care but that ultimately the decisions about his care was made by the dermatology team which our adviser said were the appropriate specialist team to recommend treatment appropriate to his needs. As such, we have found no failings in relation to this part of the complaint.
59. We were sorry to hear of what Mr O and his family went through and do not underestimate the upset and distress caused by the surgery he underwent while he was trying to recover from his stroke. We hope it reassures Mr O and his family to know that we have not found any failings in the care and treatment provided to Mr O by the Trust.