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Mr B underwent complex bowel surgery in July 2011with a view to managing unpleasant symptoms. He very sadly died six days later. My investigation considered the following complaints:

– the extent and risks of surgery were not fully explained to Mr B;

– there were insufficient investigations and bowel preparation prior to surgery, and the surgery itself was not appropriate; and

– Mr B’s partner was not told of the outcome of surgery until he deteriorated.

The Health Board said that there had been a ‘long and detailed consent process’. However, there was no evidence of this. I upheld the complaint and found that Mr B was only made fully aware of the extent of the surgery shortly before he was taken to theatre. I concluded that he was not made aware of all the potential risks involved, and that he went into major surgery, which ultimately led to his death, without having been fully informed or being in a position to give proper consent.

My investigation found a divergence of opinion about whether pre-surgery investigations were needed. None were undertaken. However, it was suggested that Mr B’s case should have been discussed within a multi-disciplinary team forum prior to surgery, and I asked the Health Board to consider this.

Having carefully considered all the evidence, I concluded that the surgery was too risky for symptom control only, unless Mr B had wished to proceed on a fully informed basis. I found that the surgeon was acting at the limit of his skills in undertaking such complex surgery. I upheld this complaint. Finally, I found that it would have been good practice for Mr B’s partner to have been told of his deterioration sooner than she was and I also upheld this complaint.

I made a number of recommendations to the Health Board which it agreed to implement. These included a payment of £5000 to Mr B’s partner for the distress caused by the failings identified, and to acknowledge the uncertainty she lives with over whether Mr B might have lived.

A copy of the full report can be found below.