NHS Grampian has been told to apologise after a patient who stepped on a rusty nail had to wait eight months for treatment – only for their surgeon to almost amputate the wrong toe.
The Scottish Public Services Ombudsman (SPSO) has asked the health board to make a number of changes, and provide evidence of them, following the incident at Woodend Hospital.
It received a complaint from someone, known only as C, on behalf of their parent, called patient A in its newly-published decision report.
After stepping on a rusty nail, A went to their GP and was then referred for treatment on their painful toe at Woodend Hospital, Aberdeen.
But rather than being seen by a specialist within 12 weeks, the patient had to endure a wait of almost eight months.
During that time, their GP had to send a second referral in the hope of speeding the process up.
Once they had been seen at Woodend Hospital, it was decided that A’s fourth toe would need to be amputated.
However, C claimed the surgeon had been incorrectly planning to remove the patient’s fifth toe instead.
The SPSO noted: “While the decision to amputate the fourth toe was reasonable, we noted that there was nothing in the medical records recording the misunderstanding about which toe was to be amputated.
“We also found that the specific risks of the amputation surgery were not mentioned to A at the clinic appointment at which the proposed surgery was discussed.”
C also complained to the ombudsman that A had not respected appropriate care and treatment following the surgery.
When their parent’s wound was not healing, they said the hospital consultant failed to carry out a pulse test to check their circulation.
As a result, they were not referred to a vascular surgeon for further investigation.
The ombudsman’s decision report said: “We found that A’s pulses should have been assessed at the clinic appointment at which amputation surgery was discussed, and this should then have led to investigations and vascular input prior to surgery, if an abnormality had been detected.
“We considered that the failure to carry out this assessment was unreasonable.”
Told to apologise
NHS Grampian has been told by the ombudsman to apologise to C and A for failing to deal with the referral in a “reasonable manner” and timescale, mentioning the specific risks of surgery, noting the “misunderstanding” around amputation and assessing the patient’s pulses.
The SPSO has also told the health board to ensure pulses are assessed and recorded at clinical appointments when foot or ankle surgery is being considered, and to ensure patients are told of the specific risks of an operation.
It has also said NHS Grampian should have “appropriate systems” in place to assess GP referrals in cases such as this one, and ensure any misunderstandings about surgery are recorded in patient medical records.
A spokeswoman for the health board said action has already been taken, and added: “The care we provided in this case fell short of the standards we set ourselves.
“We have already contacted to C and A to offer a formal apology and we would take this opportunity to do so again, publicly, and unreservedly.
“All the recommendations made by the ombudsman have been accepted and implemented.”