SCOTLAND'S top public services watchdog has uncovered "systemic failures" at a health board after a patient who went under the knife at one of the country's largest hospitals was left paraplegic following a series of blunders.
The operation to repair an aneurism in an 82-year-old man at the Royal Infirmary of Edinburgh was prolonged by four hours after surgeons realised that a piece of surgical equipment, needed to deal with an unexpected blood leak, was missing. Instead, one had to be rushed 55 miles from a hospital in Dundee and experts said the delay had a "negative impact" on the final outcome.
The fact that the patient was unable to move his legs following the eight-and-a-half hour operation was then not reported to medical staff by a nurse until the next morning, delaying the identification and treatment of a epidural haematoma - a collection of blood pressing on the spinal cord - which the patient had developed. An operation to repair the haematoma was then unsuccessful, leaving him paralysed from the waist down until he died 20 months later.
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Jim Martin, the Scottish Public Services Ombudsman, said there had been "several very serious failings" and that "extreme distress" had been caused to the patient and his family.
Sarah Ballard-Smith, NHS Lothian's nurse director, expressed"sincere condolences" to the daughter-in-law of the patient and said the trust had accepted the Ombudsman's recommendations, "which include reinforcing the effectiveness of the surgical safety check list, re-emphasising the escalation and consent process and ensuring that relevant staff are aware of the vital importance of good record-keeping.