The Commissioner has reviewed the care provided to a young man who died following brain surgery. The Commissioner identified a number of systems issues which compromised the ability of staff to provide appropriate care, and also suggested that patients ought to be told who will perform their surgery as part of the consent process.

The Commissioner found that there were a number of organisational issues that impacted adversely on the quality of postoperative care and which "conspired to create an unsafe situation in which appropriate monitoring did not take place". In particular, the Commissioner identified a conflict between ward protocols and the consultant's instructions; failures to record the patient's respiratory rate (which were compounded by the Neurosurgery observation chart not having a specific place for such recordings); and a number of ward practices that impacted on patient care (e.g. the location of handover, and "specialling" ending on the completion of the night shift rather than at medical handover).

Although no breach finding was made in relation to the consent process, the Commissioner commented that in many circumstances a reasonable patient would expect to be told the identity of the person performing the surgery, in order to give proper informed consent. In this case, the consultant and registrar were involved in the consent process but the patient was not told that the registrar would perform the surgery. 09HDC01565