A patient who suffered complications during surgery was abandoned for more than 24 hours at the north-east’s flagship hospital – because his locum consultant caught a flight home to Belgium.
The man was admitted to Aberdeen Royal Infirmary for routine keyhole surgery on his gall bladder.
But he then spent a further two weeks in hospital because problems developed after his operation.
An internal review of the way locums are hired by NHS Grampian was launched after another medic complained about the case.
And the inquiry revealed the system for appointing stand-in doctors and allocating their caseload was in chaos.
The continental locum was left with no clinical mentor when he arrived at ARI and “very junior” surgical trainees to assist him in theatre.
After the operation, the locum did not carry out the correct handover to the on-call consultant and left the hospital to fly home without the right post-operative care in place.
As a result, the recovering patient was left on the wrong ward – normally reserved for orthopaedic patients – with no senior member of the surgical team knowing he was there.
The patient told the review team he felt “something had gone wrong” during surgery given that no one came to see him.
The internal report said: “The locum consultant tried to hand over the patient to the consultant on call, but was unsuccessful and describes a conversation with a surgical trainee, though the consultant on call did not receive the call or was informed of the patient’s presence in ward 212.
“The patient had no recollection of this visit and was of the opinion that ‘something had gone wrong’ during surgery as no medical staff subsequently came to see him on 212 to explain the procedure to him or his partner.”
The report found that staff may not have been fully aware of new ward numbers and specialities leading to a “possible inappropriate transfer” of the patient to ward 212.
It took more than 24 hours to move the patient to a surgical ward, and it was “unclear” why this had not happened sooner, the report said.
Patients groups last described the episode as a “shambles” with “unacceptable” levels of support for locums arriving in Aberdeen – to the risk of patient care.
The blunders emerged at a time when the health board is becoming increasingly reliant on locum cover to stem a shortage in hospital consultants, but NHS Grampian said improvements had been made to the way stand-in doctors were hired.
The report found the locum arrived to work at ARI for two weeks in March 2014 at a time of high rates of leave by managers and clinicians.
But a need for “urgency” to secure medical cover meant that full policies on hiring locums were not followed, with poor communication between managers and clinicians.
Different medical secretaries placed patients on different vacant theatre lists with no understanding of the workload created, the report said.
An error on the booking form meant that the named clinical mentor for the locum was on leave when he started at ARI.
He was given no full orientation or administrative help and was left without passwords to access clinical records. He also racked up a number of parking tickets after no space in the hospital grounds was allocated for him.