However, the Scottish Public Services Ombudsman (SPSO) has, after an investigation, urged the local health board to ensure that medical records reflect discussions with patients over treatment options.
In the background to last week’s decision, the SPSO explains that the patient (referred to as Mr C) was concerned that, given previous surgery, he should not have been offered ERCP – a procedure which uses a flexible tube to examine the bile duct, located in the small intestine.
“Mr C complained the ERCP was not carried out in an appropriate manner and led to the need for further surgery and treatment which were also not carried out in a reasonable manner,” states the watchdog.
“We took independent advice from a consultant general surgeon. The advice we received was that the care and treatment provided to Mr C was appropriate and reasonable.
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“Mr C suffered a number of recognised complications following what the adviser considered was a reasonable decision to offer him ERCP. The advice we received was that the clinical management decisions made in his care and treatment were in accordance with accepted good practice.”
The patient also alleged he was not given “appropriate information” on what would happen if a procedure to drain his bile duct was unsuccessful.
“We found that the medical records did not detail any discussion held with Mr C about alternatives to ERCP and failed to detail what advice he was given,” states the SPSO. “We therefore upheld this aspect of the complaint.”
A spokesperson for NHS Borders told The Southern: “While the SPSO did not uphold this complaint [over care and treatment], we have taken learning from this case which has been used by our clinical team to make improvements to the information provided for our patients.
“We are also making changes to the way discussions about treatment options are recorded.”