Annual Report 2007-08 - the Parliamentary and Health Service ...

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21Case StudyApology acknowledged failingsin consent for breast surgeryIn December 2004 Mrs M was referred by her GP for amammogram which showed that she had small tumours in bothbreasts. A bilateral mastectomy (surgery to completely removeboth breasts) was recommended.In February 2005 Mrs M attended Torbay Hospital where she wasprovided with information about her condition. Mrs M discussedthe issue of scarring with the Breast Care Nurse and emphasisedthat the position and cosmetic appearance of the resulting scarswere both very important considerations for her. Later thatmonth, the Consultant Surgeon who was to perform theoperation gave Mrs M a consent form to sign; however, she hadyet to decide whether she would proceed with the proposedsurgery and did not sign the form immediately.In March 2005 Mrs M signed the consent form. She was admittedto Torbay Hospital in early April 2005, and underwent a bilateralmastectomy. When the bandages were removed, Mrs M washorrified to discover that, rather than two scars below the breastline, as she had been expecting, she had been left with whatappeared to be a single horizontal scar across her chest wall,above her breast line. Mrs M was shocked and extremelydistressed by the extent, position and appearance of her scarringand raised her concerns immediately with a member of the SouthDevon Healthcare NHS Foundation Trust’s staff. Mrs M wasdischarged the next day.Two days after her discharge, Mrs M complained to the Trustin writing about the appropriateness of the surgery and theconsent procedure in relation to the nature and extent ofpotential scarring. The Chief Executive responded to thecomplaint in September 2005 and said that the bilateralmastectomy was the correct procedure and that the surgeonhad acted appropriately.Mrs M remained dissatisfied and in October 2005 she complainedto the Healthcare Commission, which found that the procedurewas appropriate and the scarring within normal range. It did,however, find shortcomings relating to consent and asked theTrust to look at those issues (both in terms of reminders to staffabout the importance of ensuring that consent forms arecompleted fully, and giving patients the opportunity to askquestions when there is a time lag between consent being givenand an operation carried out) and to inform Mrs M of resultingchanges in policy. The Commission, in two replies (February andMarch 2006), concluded that despite the shortcomings identifiedconsent had been obtained on a properly informed basis.In April 2006 Mrs M complained to the Ombudsman. Mrs M madeclear that she had pursued her complaint in order to have itacknowledged that the operation she received was not the onefor which she gave consent, not to obtain financial compensation.46
Parliamentary and health service ombudsman annual report 2007-08We found that the bilateral mastectomy was an appropriateprocedure for Mrs M and that some parts of the consent processwere reasonable. However, we noted that there was no review ofthe consent at the time of the admission immediately before theoperation. We also concluded that, based on the informationgiven to Mrs M pre-operatively, it would have been reasonablefor her to expect two separate scars running horizontally acrossthe lower to middle part of her chest. We found that overall therewere sufficiently serious shortcomings in the consent processto undermine the validity of the consent.The investigation found that, having reviewed appropriateevidence and sourced appropriate advice, the Commission’sresulting decision that Mrs M’s consent was fully informed wasunreasonable. It did not properly reflect the evidence assessedor clinical advice received, and this caused Mrs M additionalinconvenience and distress.As a result of our recommendations, the Trust and theCommission agreed to apologise to Mrs M for the shortcomingsidentified in our report and the injustice she had suffered.In addition to the action it had taken as a result of theCommission’s recommendations, the Trust also agreed to giveMrs M an assurance that lessons had been learnt from hercomplaint and an explanation of the changes made to preventsuch failures being repeated.47
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