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Case ref:201406257
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Date:January 2016
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained that a trans-abdominal (TA) ultrasound scan (performed by passing the scanning device over the abdomen) she had received at Glasgow Royal Infirmary had not been properly carried out. As a result, she had been forced to seek private treatment. This had consisted of a gynaecological (relating to the female genital tract) examination and a trans-vaginal (TV) ultrasound scan (performed through the vagina, using a slim probe), as well as a TA scan. Three gynaecological problems were identified which Mrs C said the board would have identified if the scan had been done properly. Mrs C also complained that the board had failed to respond to her complaint properly.
We received independent advice from a consultant sonographer (a doctor who performs and analyses diagnostic ultrasound tests). The adviser said that the board's appointment times were too short to carry out the two separate types of scan needed in this case. The adviser noted, however, that of the problems identified during the private consultation, only one would have been apparent had Mrs C received both types of scan. We were advised that the outcome for Mrs C would not, therefore, have been different had she received both types of scan.
We found that, although there was no evidence the short appointment had caused Mrs C harm, she had not received the appropriate scans for her gynaecological condition. We found that the board had, however, responded appropriately to Mrs C's complaint.
Recommendations
We recommended that the board:
- review its standing operating procedures to ensure they provide greater clarity on when a trans-vaginal scan should be performed;
- review the time allocated for ultrasound appointments taking into account any relevant guidance; and
- apologise for the failings we identified.