Poor record keeping meant trust could not fully respond to complaint about hernia surgery

What happened

Mr G had hernia repair surgery but was readmitted to hospital several days later in severe pain. He was given pain relief but readmitted some time later, again with uncontrollable pain. It seems that over time, Mr G developed neuralgia (pain from a damaged nerve) in the area.

What we found

We partly upheld this complaint. Mr G experienced chronic pain following his operation. However, this is a well–recognised complication of hernia surgery: between one and four patients in every 100 could experience chronic pain. In Mr G's case, the most likely cause was nerve damage during the operation. This does not necessarily mean that anything went wrong during the surgery, but we could not say because the Trust was unable to supply us with the operation notes. This was a failing in the Trust's record keeping.

Before the operation, the Trust should have warned Mr G that there was a risk of chronic pain, discussed this with him, and given him a chance to ask questions. However, although the Trust recorded that it discussed other side effects with Mr G, there was no record that staff mentioned pain. Again, this does not mean that the Trust did not explain this to Mr G, but there is no evidence that it did. This was a further failing by the Trust.

It is likely that the complications Mr G experienced would have happened anyway, because there is a well–known risk of pain after this type of surgery. After the operation, the Trust carried out the standard investigations into Mr G's pain and treated him appropriately. Chronic pain after hernia surgery is a complex and difficult issue. The Trust referred Mr G to the pain clinic for ongoing treatment, which is in line with established good practice.

Gaps in the records prevented the Trust from giving Mr G a satisfactory answer to his complaint. This was frustrating for Mr G and made the complaints process longer than it should have been. Because of this we partly upheld Mr G's complaint.

Putting it right

We recommended that the Trust improve its record keeping, given that there were no notes from Mr G's operation.

We also asked the Trust to improve the consent process before surgery. We recommended it introduces the pre-printed consent forms in use across many NHS trusts in England. These forms list the possible risks of a procedure with a tick box alongside each one. This helps to reduce the risk of human error.