Decision Report 202000350

Summary

C complained about the care and treatment that they received from the board. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect.

C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain.

Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint.

We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.