Scotland's health watchdog has ordered NHS Lothian to apologise after a titanium clip was left up a patient's nose for 28 months.
The Scottish Public Services Ombudsman (SPSO) reported the patient known as Ms C complained after the health board unreasonably failed to discover an object left in her nasal tissue after surgery at St John's Hospital in Livingston.
It took NHS Lothian 16 months after her initial operation which was to have stents (splints placed temporarily inside a duct, canal, or blood vessel to aid healing or relieve an obstruction), removed from her nose - for a routine scan to reveal that a titanium clip was still in place that had been left over from the surgery.
Incredibly, the board then took the decision not to remove the object for another 12 months before it was eventually taken out.
The SPSO report said that on removal of stents one came away in two pieces and Ms C was alerted at the time that a piece of silicone stent may have been retained.
She continued to attend the hospital for treatment of chronic rhinosinusitis - a condition where the cavities around the sinuses become inflamed and swollen for a prolonged period.
Sixteen months after the surgery, a routine scan was carried out which identified that a titanium clip had indeed been retained in the nasal tissue.
However the silicone stent and titanium clip were removed at the same time Ms C was undergoing another surgery, approximately one year after the retained titanium clip was discovered.
The SPSO report said : "We took independent medical advice from a consultant rhinologist (a specialist in conditions affecting the nose). We found that the board unreasonably failed to discover and report on all elements retained in Ms C's nasal tissue after surgery.
"No investigations were carried out until the scan 16 months after the stents were removed, where it was found that the titanium clip was still in place.
"After it was discovered, it was over a year before it was removed.
"We found that there was an unreasonable delay in identifying the retained titanium clip."
The SPSO upheld this part of Ms C's complaint.
She also complained that the board failed to provide a reasonable explanation as to how an object was left in her nasal tissue after surgery.
SPSO added: "NHS Lothian accepted they had not provided a reasonable explanation.
"The communication regarding this issue was poor.
"When it was found that a titanium clip had been retained as well as the silicone stent, it was over four months before Ms C was informed of this.
"No explanation was provided as to why the clip was retained or why Ms C was not informed that this was a possibility.
"We considered that the board could have been more open and detailed about what happened and why.
"Therefore, we upheld this part of Ms C's complaint."
The SPSO have ordered NHS Lothian to apologise to Ms C for the failings identified by this investigation.
They say the apology should meet the standards set out in the SPSO guidelines and have listed a number of recommendations the health board should act upon to put things right in future.
These include: A review of practice to consider best practice to secure silicone tubes for dacryocystorhinostomy (DCR) surgeries.
A review of the process for selecting patients for DCR surgery.
Clinicians should review their diagnosis when patients do not respond to treatment.
Learning from this investigation is fed back to relevant staff in a supportive way and the process of discussing options and consent to treatment should be clear in its documentation.
Dr Tracey Gillies, Medical Director, NHS Lothian said: “I would like to take this opportunity to apologise again to Ms C.
“We have accepted the report from the Ombudsman and have implemented the recommendations in full.”