Decision Report 201406517

  • Case ref:
    201406517
  • Date:
    January 2016
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, action taken by body to remedy, no recommendations
  • Subject:
    hygiene / cleanliness / infection control

Summary

Mrs C complained to us on behalf of Mrs A, in relation to an incident of potential contamination due to the use of unclean equipment. Mrs A attended Dundee Dental Hospital for treatment, and during the course of her treatment a microscope was put close to her mouth. She could see dirty marks on the microscope which looked like dried blood. After her treatment she raised concerns with staff. One nurse immediately wiped the microscope. Mrs A said that she was told it would be sent for analysis. Later that day staff contacted Mrs A to provide further information and advice.

Following Mrs A’s complaint to the board, they took further steps to investigate the situation, and identified failures in the board’s cleaning protocols, which were rectified.

We took independent advice from one of our nursing advisers, which indicated that, while it was not appropriate for dirty equipment to be in use, the board had identified gaps in their protocols and had made appropriate changes. She also considered that the information and advice provided to Mrs A and her husband were reasonable. The adviser was also satisfied that appropriate action was taken in cleaning the equipment, and did not express concerns that the wipe used to clean it had not been analysed.

We concluded that Mrs A was understandably upset by what had happened. However, we found that it had been appropriate to clean the equipment as soon as possible, and not taking a sample for analysis was in line with national policy. We also considered that the information and advice Mrs A was given were appropriate. We found that the board’s response to the complaints made and the action taken were reasonable.

Updated: March 13, 2018