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Selected Investigations Completed April - September 1999 > Part I, Case no. E.1394/97-98
Complaint against: The Royal Hospitals NHS Trust (now Barts and The London NHS Trust)
Summary of case
During his pre-operative assessment for a hernia repair, in September 1996, Mr Y's blood pressure was recorded as being above normal, although he was not aware of that. It was intended that further checks would be made when he came in soon afterwards for his operation which, he was assured, would not be cancelled. His blood pressure was taken again when he was admitted the day after the assessment, because of concern about some other test results. He was discharged again the same day. However, the operation was cancelled and, while he was awaiting a new date, he suffered a haemorrhage in one eye leading to a permanent defect in his sight. Later, Mr Y learned of the first blood pressure reading and was told by an ophthalmologist that high blood pressure might have been the cause of his haemorrhage. He complained that the operation should not have been cancelled, and that if action had been taken at the time of the high reading, or if he had been warned of it, he might have avoided the problem with his eye.
Findings
The Ombudsman took advice from three doctors on clinical aspects of the complaint. Although the need for the hernia surgery itself was not urgent, it was delaying other surgery Mr Y needed and the surgeon wanted to make sure the operation was not cancelled. However when it was booked, administrative staff were not made aware of the commitment given to Mr Y about that. The Trust's policy on admissions was not followed to the letter: but even if it had been, the operation might still have had to be postponed. The commitment given to Mr Y was not fulfilled and to that extent, the Ombudsman upheld the complaint about the cancellation of the operation. The Ombudsman also found that the haemorrhage could have been caused by high blood pressure. Although the blood pressure reading taken at the pre-assessment clinic was above normal, the decision then simply to check it again was reasonable. However the reading taken the next day was very high and action of some kind should have been taken. There was no evidence that the Trust taking any other action about it, though they had lost some of the records. The Ombudsman upheld the complaint that staff took insufficient steps to control Mr Y's blood pressure.
Remedy
The Trust apologised to Mr Y and agreed to review the way in which they implemented their admissions policy. They had already agreed to take steps to reduce the risk of records being lost.
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