-
Case ref:201806301
-
Date:August 2019
-
Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
-
Sector:Health
-
Outcome:Upheld, recommendations
-
Subject:clinical treatment / diagnosis
Summary
Mrs C complained on behalf of her daughter (Miss A) about the care and treatment that Miss A received at the Royal Hospital for Sick Children (Yorkhill) for a cyst on her kidney. Mrs C said that there was no transition management to help Miss A prepare for moving from children to adult services; about the decision to move Miss A to adult services; that she was discharged from the board's care prior to being successfully treated for a cyst; and that there was a delay in Miss A receiving a second operation to remove the cyst as a result of the move to adult services.
We took independent advice from a paediatric and adolescent (branch of medicine dealing with children and their diseases) consultant. We found that it was reasonable for the board to have discharged and transitioned Miss A to adult services at the time that they did. However, we also found that there were failings in the care provided to Miss A, specifically that there was a failure to have a coordinated plan and process in place to support Miss A's transfer from paediatric to adult services which led to a delay in treatment of the cyst. We upheld Mrs C's complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Miss A for failing to transition her appropriately from paediatric to adult services. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- There should be guidance in place for staff which sets out a clear pathway for transition from paediatric to adult services, including the age range and the degree of flexibility possible.
- Patients transitioning between paediatric to adult services should have a coordinated plan in place and this should be documented.
- A process should be in place for the transition from paediatric to adult services for clinicians to use to guide transition management.
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.