Decision Report 201802815

Summary

Ms C, an advocacy worker, submitted a complaint on behalf of her client (Ms A). Ms A was diagnosed with polycystic ovaries (a condition that affects a woman's hormone levels) after undergoing a laparoscopic (minimally invasive) surgery to untwist a torted right ovary. Further investigations were carried out, including two ultrasound scans. After experiencing severe lower abdominal pain, an emergency salping-oophorectomy (removal of the fallopian tube and ovary) was carried out. This took place two days after Ms A's second ultrasound. Ms C complained that the second ultrasound scan was not carried out appropriately and that an ultrasound scan should have taken place when she was admitted to hospital inbetween her two other scans.

We took independent advice from an obstetrics and gynaecology consultant (a  doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that it was reasonable for the board to not carry out an ultrasound scan during Ms A's admission. We noted that Ms A's condition appeared to have been managed appropriately and conservatively, based on the information known at the time. We also found that an ovarian torsion can happen over a few hours and, therefore, it is possible that it had not occurred when the second ultrasound took place. We acknowledged that it was not possible to know for certain whether anything of concern was overlooked during this ultrasound, however, we considered that the board's management of Ms A's condition was reasonable and appropriate. We did not uphold either of Ms C's complaints.