Decision Report 201800216

  • Case ref:
    201800216
  • Date:
    February 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mrs C complained about the treatment she received at an appointment with a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) at Ninewells Hospital and the response to her subsequent complaint. Mrs C said the doctor failed to properly investigate her condition given her symptoms/medical history and that there were failings in communication.

We took independent advice from a specialist in gastroenterology. We found that there were failings in relation to documenting Mrs C's medical history and this meant she was left with the impression that the doctor did not take her symptoms seriously, especially her neurological symptoms. While we note not everything that would have been discussed was in the consultation records, we determined that the standard of medical care was not reasonable and this led to a breakdown in the relationship with Mrs C. We upheld this part of the complaint.

In relation to complaints handling, we found that the board's response to the clinical issues raised was reasonable based on Mrs C's medical records. Therefore, we did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for the failings in the way the consultation was conducted. 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:

  • The doctor involved should reflect on the complaint and our findings in their next appraisal.
  • The board should consider a neurology referral in light of our findings.
  • Sufficient time/input from experienced clinicians should be accomodated for consultations anticipated to be complex.

Updated: February 20, 2019