Decision Report 201705257

Summary

Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in childbirth and the female reproductive system). We found that the handling of Mrs C's referral to physiotherapy was unreasonable and caused a delay of around seven months in her receiving her first appointment. We acknowledged that the board had apologised to Mrs C for the failure to action the referral to physiotherapy and for problems both Mrs C and her GP had when trying to expedite the referral through the doctor's secretarial staff. We considered that there was an unreasonable failure to amend Mrs C's management plan (regarding the decision to refer her for physiotherapy) after she was reviewed post-operatively.

We found that there was poor internal communication across two hospital sites and a missed opportunity for the problem with the referral to be addressed at an earlier stage when Mrs C and her GP contacted the doctor's support staff. We considered that the board had taken reasonable action to improve communication between hospital sites. We considered that the delay in receiving physiotherapy was unlikely to have affected the progression of Mrs C's condition. However, we upheld the complaint and made a further recommendation to ensure learning and improvement.

In terms of the board's handling of Mrs C's complaint, we acknowledged that they had apologised to Mrs C about their delay in responding. We found that the board had delayed by three weeks in updating Mrs C when they were unable to meet the 20 working day timescale for responding to complaints. Were were also critical that the board had not responded to all of the concerns Mrs C had raised in her complaint correspondence. The board accepted that they should have responded to this aspect. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to all aspects of her complaint.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should ensure that management plans are updated between theatre and post-operative review.