Decision report 201004653

Summary
Miss C suffered from abdominal pain and attended A&E on three occasions between July and August 2008. Appendicitis was suspected, but Miss C's symptoms settled and she was discharged after a short admission on the first two occasions. On the third admission, her symptoms did not settle and a laparoscopy was carried out to diagnose the cause of her pain. During the procedure, her appendix was removed and she was noted to have an inflamed uterus and fallopian tubes. Miss C continued to have recurrent abdominal pain following surgery.

Miss C complained that, at a routine doctor's appointment in 2010 she was told that she had been diagnosed with Pelvic Inflammatory Disease (PID) in August 2008. She had not been made aware of this diagnosis and complained that she had not been treated for it. She also questioned why her appendix had been removed.

We found that a provisional diagnosis of PID was made during the laparoscopy in August 2008. Miss C was treated empirically for PID with a course of antibiotics. We were satisfied that the removal of her appendix was in line with standard practice during laparoscopies. However, we found no evidence of Miss C being informed of her presumed diagnosis of PID or of another diagnosis that was also made at the time. Whilst treatment was clearly provided for her PID, we concluded that the combination of antibiotics used and the dosages prescribed were not in line with guidelines on the treatment of this condition. Furthermore, there was no evidence of any treatment being provided for Miss C's other condition.

Recommendations
We recommended that the board:
• review their procedure for obtaining patient consent to ensure that it is in line with the Scottish Government's Good Practice Guide for Health Professionals in NHS Scotland;
• provide the Ombudsman with details of any action they have taken, or propose to take, to ensure that patients are provided with information about the surgical team's findings;
• review their approach to treating patients with PID to ensure that the medication used is in line with the guidance in the Royal College of Obstetricians and Gynaecologists' document, Management of Acute Pelvic Inflammatory Disease;
• ensure that any future treatment that Miss C receives for PID is in line with the guidance in the above document; and
• apologise to Miss C for the issues highlighted in this decision letter.