Decision Report 201406219

Summary

Ms C was referred to the former Southern General Hospital in Glasgow by her GP for investigation of secondary infertility. A HyCoSy scan (a procedure to detect whether the fallopian tubes are damaged or blocked) and blood tests were arranged. The board took ten months to arrange the scan. Ms C said that because of the time it was taking to see a consultant gynaecologist to discuss the results of the scan and as the board could not provide her with a timescale of when she would get an appointment and as she was suffering severe abdominal pain, she arranged to be seen privately by a consultant gynaecologist abroad. The private consultant gynaecologist reviewed the results of her HyCoSy scan and carried out an ultrasound scan and, as a result, recommended a laparoscopy to confirm and, if necessary, treat endometriosis. A laparoscopy is surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin.

Ms C said that although she presented this information to the board's consultant gynaecologist, they refused to arrange a laparoscopy. Ms C said she paid for the laparoscopy procedure abroad. It confirmed a diagnosis of endometriosis and she had surgery to treat and cure her symptoms.

We took independent advice from a consultant gynaecologist. We found that there was an unacceptable delay in arranging Ms C's HyCoSy scan, the result of which was not normal and that a laparoscopy should have been arranged for Ms C by the board. Based on the clinical advice we received, we were satisfied that the board should have offered Ms C a laparoscopy to provide the definitive diagnosis. Therefore, we upheld Ms C's complaint.

We were also critical that the board were unable to locate and provide us with Ms C's complete clinical records and we made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in arranging a HyCoSy scan, the failure to offer her a laparoscopy and for losing her medical records;
• refund to Ms C the invoiced cost of her ultrasound scan, laparoscopy and associated treatment arranged abroad;
• provide evidence that the delay in carrying out the HyCoSy scan has been addressed;
• feed back the comments of the adviser and the findings of this investigation to the consultant gynaecologist for reflection and learning, to include the importance of the management of medical records; and
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)'.