SURGEONS were forced to apologise to a recovering cancer patient who was left in “unnecessary pain and discomfort” after a botched operation on her back.
The woman was operated on at the Western General Hospital, Edinburgh, in June 2012, but the next year it emerged the wrong part of her spine had been treated.
Her husband complained that the pain had “impacted significantly” on his wife’s life as she recovered from radiotherapy treatment for breast cancer.
Yesterday, the Scottish Public Services Ombudsman (SPSO) upheld a complaint that the care had been “unreasonable” and made a series of recommendations for the two health boards involved.
The patient, known only as “Mrs C”, underwent a surgical procedure at the end of her radiotherapy to have an implant inserted between vertebrae for a long-standing back complaint. The operation was carried out by a senior registrar in neurosurgery at the Edinburgh hospital.
However, when Mrs C felt unwell in the weeks after the operation, experiencing pain in her left leg, another X-ray was taken, followed by an MRI scan at Borders General Hospital in Melrose in December.
The patient contacted the Western General about her scan and after Borders General was reminded, the MRI was sent to the Edinburgh hospital, where it was viewed by the consultant neurosurgeon, who realised the implant had been inserted at the wrong part of the spine. The consultant phoned Mrs C to apologise, before the operation was redone.
In its report, the SPSO said NHS Lothian had blamed an “error of judgment” by the senior registrar carrying out the initial operation. The ombudsman said that had an X-ray been taken during the operation, once the wound was open, it could have determined that a mistake had occurred.
The ombudsman, Jim Martin, said: “The [NHS Lothian] board have already made an apology to Mrs C so I do not require them to do so again.
“However, I recommend that the consultant neurosurgeon revisit her procedures for determining the level of surgery and consider doing two X-rays, one before incision and one with the wound open. Alternatively, do only one X-ray, but with the wound open and the spinal elements clearly visible.
“Further, I recommend that [Borders General] review their procedures concerning the timely dispatch of radiology reports.”
Tracey Gillies, associate medical director at NHS Lothian, said: “This was a very unusual and isolated case, but we have taken a number of steps to help prevent a repeat of a similar incident, including revising surgical protocols to ensure the correct positioning in future operations.”
Dr Sheena MacDonald, medical director at NHS Borders, added: “NHS Borders accepts the recommendation from this report and can confirm that revised measures are now in place concerning the timely dispatch of radiology reports.
“At the time of the incident, the radiology department was experiencing significant demand and capacity issues, which have since been addressed with the recruitment of an additional consultant radiologist and radiographer.”