Decision Report 201602890

Summary

Ms C complained about a transvaginal ultrasound scan (an internal pelvic scan used for examination of a woman's reproductive organs) carried out at Dumfries and Galloway Royal Infirmary. Ms C complained that she was kept waiting unnecessarily, that inappropriate and unclean equipment was used and that the procedure was carried out in an overly rough manner which she felt led to vaginal and bladder infections. Ms C also complained about the way her complaint was handled.

During our investigation we took independent medical advice from a consultant obstetrician and gynaecologist with a special interest in ultrasound scanning.

We found that a member of staff should have checked on Ms C's wellbeing while she waited for her scan so we upheld that aspect of her complaint. We found that there was no evidence that the equipment was inappropriate or unclean so we did not uphold those aspects of the complaint. We found that while these types of scans can sometimes cause vaginal or bladder infections, this would not necessarily indicate that the scan was carried out improperly or in too rough a manner, so we did not uphold this aspect of the complaint.

In relation to complaints handling, we found that there was a delay in responding to Ms C's complaint which the board did not acknowledge, and we therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not updating her on the delay in her appointment and not checking on her wellbeing while she waited for her scan. Further apologise for the delay in acknowledging Ms C's complaint. These apologies should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients should be kept updated if appointments for scans are delayed and it should be explained to them why they are waiting longer. Staff should check that patients are comfortable and should tell the sonographer is a patient is in discomfort or is highly anxious.
• The board should consider providing patients with an information leaflet in advance of their appointment. It should include information about what to expect on the day and warn about the possibility of delay. It should also detail the staff help and support available on the day, how patients can raise any concerns at the time, the clothes changing facilities available and the small risk of infection for all invasive procedures.
• Patients should be asked if they are feeling ok after the scan has started as some patients may not express concern unless prompted.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.