Decision Report 201809500

Summary

C complained about the care and treatment provided to them by the board when they presented with abdominal pain. C complained that they were repeatedly unnecessarily catheterised, their symptoms and clinical context were ignored, and they were misdiagnosed as having a bladder tumour instead of an ovarian tumour.

We took independent advice from a nurse, a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a urologist (a doctor who specialises in the male and female urinary tract, and the male reproductive organs), and a sonographer (a healthcare professional who performs diagnostic medical sonography, or diagnostic ultrasound). We found that both nursing and urology care and treatment provided to C was reasonable. However, we found that an ultrasound scan incorrectly interpreted a mass as being a bladder tumour, when in fact the mass represented a large ovarian tumour. Though this was a misinterpretation of the scan, we found that given the clinical information available at the time, this misinterpretation was not unreasonable. We did not uphold this aspect of C’s complaint.

C also complained about the board's handling of their complaint. We found that there were significant complaint handling failings, including failure to advise C in a timely manner which aspect of the complaint they would investigate; failure to update C in a timely manner throughout the investigation; incorrect information being contained in the complaint response and no apology being given for this. We therefore upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable handling of their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Staff should be aware of the scope of a complaints investigation and the relevant standards and processes that apply. Staff should be able to appropriately obtain and evaluate the evidence obtained and use this to give reasons for decisions reached; and complaints should be handled in line with the model complaint handling procedure. SPSO have issued a guidance tool to support investigations staff. This can be accessed here: www.spso.org.uk/how-we-offer-support-and-guidance. The model complaints handling procedure and guidance can be found here: www.spso.org.uk/the-model-complaints-handling-procedures.

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.