Decision report 201103184

Summary
Mrs C, an advice worker, complained on behalf of Mrs A. Mrs A said that a nurse at her medical practice cut her internally during a smear test, leaving her with injuries. Mrs C complained that the nurse did not acknowledge her failings and that the practice failed to deal appropriately with Mrs A's concerns about her treatment.

During our investigation, we obtained copies of the patient complaint log, the minute of an investigatory meeting held by the practice to discuss the complaint and the practice's complaints procedure. We also asked the practice for information about the complaint.

The practice said they accepted that initially the nurse did not acknowledge her failings in carrying out the attempted smear. They expressed concern that she failed to react appropriately at the time or to acknowledge this later. The documentary evidence showed that the practice noted these concerns at the time of their investigation of the incident. We upheld the complaint about the nurse.

Mrs C complained about the practice's handling of Mrs A's concerns, in particular, the practice manager's conduct and the practice's failure to respond to a letter from Mrs C about the treatment. Having looked into this, we found that there was insufficient evidence to suggest that the practice failed to deal with Mrs A's concerns appropriately, and we did not uphold this complaint. However, there were two matters that we considered the practice could have handled better and we made recommendations to address these.

In addition to investigating these complaints, we agreed to ask the practice for evidence of the remedial action they said they had taken as a result of Mrs C's complaints. It was clear from the information we obtained that they did take some action. However, we were concerned that the practice failed to verify if the nurse asked a female GP to observe her smear taking technique, and that not all of the remedial action taken was documented. For these reasons we made a further recommendation.

Recommendations
We recommended that the practice:
• apologise to Mrs A that the nurse failed to acknowledge her failings in carrying out the attempted smear;
• write to Mrs C and Mrs A to apologise for failing to inform them that the nurse had left the practice and for failing to respond to Mrs C's letter; and
• amend their procedures for handling complaints to include the following steps: 1. to follow up on any remedial actions suggested as a result of an investigation of a complaint; and 2. to ensure that all remedial actions are documented.