Hospital failed to treat patient appropriately when his condition became unstable in operating theatre

What happened

Mr A went into hospital for surgery on his shoulder. Shortly after he was anaesthetised, he suffered a problem with his heart. The cardiac arrest team was called and Mr A was given cardiac compressions and drug treatment. Fortunately he made a rapid and full recovery and tests showed there was no ongoing problem with his heart.

Mr A believed he had suffered a cardiac arrest and asked the hospital for an explanation of what had happened to him. He thought that the event might have been linked to the fact that he had recently been taking tablets to lower his blood pressure. The hospital said that his blood pressure and heart rate dropped dangerously low but he did not suffer a cardiac arrest. Mr A was unhappy with the hospital's explanation of events and continued to believe he had suffered a cardiac arrest and that the hospital had caused this. This left him fearful about future surgery.

What we found

We looked at the clinical records and took independent clinical advice. There were significant shortcomings in the care Mr A was given. The preoperative assessment the consultant anaesthetist carried out was below expected standards but there was nothing to suggest that this had any bearing on what happened in theatre. The clinical records about Mr A's time in theatre were poor, so it was difficult to be certain about what actually happened. However, it was clear that the actions taken by the consultant anaesthetist to treat Mr A when he became unwell in theatre were inappropriate. This put Mr A's life at risk and left him with some short-term pain and discomfort. When Mr A complained, the hospital failed to give him complete and fair explanations of what happened or an apology for the shortcomings in care.

Putting it right

The hospital acknowledged the failings identified and apologised to Mr A for the injustice which resulted. The hospital also paid him £500 for the distress he suffered as a result of the poor complaint handling. We asked the consultant anaesthetist involved in Mr A's care to discuss our report with his appraiser and we shared our report with his responsible officer.