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.
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.