Decision Report 201303011

Summary

Miss C was unhappy with the care and treatment she received during her pregnancy. She complained there was a failure to provide her with appropriate clinical treatment for an ovarian cyst (a fluid-filled sac) and to provide her with appropriate nursing care during her labour. When Miss C was about 18 weeks pregnant she had experienced severe abdominal pain. She had a consultation with an out-of-hours GP, who referred her to her own GP. She was later admitted to Forth Valley Royal Hospital with a suspected torsion (where the weight of the cyst causes the whole ovary to twist, cutting off the blood supply). A laparotomy (an open operation on the abdomen) was carried out. However, when the surgery was performed, no cyst was present (it appeared to have resolved on its own) and no other reason for Miss C’s pain was identified. Miss C was later prescribed antibiotics because the surgical wound was leaking. She considered the operation unnecessary and that it could have been avoided if she had been given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) before surgery. She was also upset about the scar left by the operation, which she felt could have been avoided if she had been scanned or given a laparoscopy (keyhole surgery) instead of the laparotomy.

We took independent advice from a GP adviser, a midwifery adviser and an obstetrics adviser (a specialist in pregnancy, childbirth etc). The GP adviser said that it was reasonable for the out-of-hours GP to refer Miss C to her own GP. The obstetrics adviser said that, while performing the operation laparoscopically might have improved Miss C’s experience, the decisions to perform a laparotomy and to do so without a further ultrasound were reasonable. We found that the care and treatment provided to Miss C was reasonable in the circumstances known to the medical staff at the time.

In relation to Miss C’s complaint about nursing care during her labour, our midwifery adviser said that the midwifery care Miss C received during and following the birth of her baby was appropriate and in line with relevant guidance. Miss C was unhappy with the conditions in the room where she gave birth but, although we considered these to be less than ideal, we did not consider that they amounted to unreasonable care.

Although we did not uphold Miss C’s complaints we noted that the board intended to review the management of her care to allow any learning to be identified and ensure improvement and development if required, and so we made a relevant recommendation.

Recommendations

We recommended that the Board:

• provide us with evidence of the review of the management of Miss C's care carried out at their clinical review group meeting.