Decision Report 201704657

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Queen Elizabeth University Hospital. During a surgical procedure Ms A was diagnosed with endometriosis (a condition where the lining of the womb grows outside the womb) and she was given treatment to alleviate her symptoms. Afterwards, Ms A was discharged back to the care of her GP and her symptoms returned a few months later. Mr C considered that Ms A should have received a standard follow-up gynaecology (the branch of medicine which specialises in the female reproductive system) appointment, instead of being discharged back to her GP's care.

During our investigation we took independent advice from a consultant gynaecologist. We found that there was no clinical guidance that Ms A should have received a standard follow-up gynaecology appointment after her diagnosis. We considered that it was reasonable that the board expected that Ms A's treatment would improve her symptoms. We further considered that, even if the board suspected her symptoms might return, it is possible for endometriosis to be managed by a GP, with advice from gynaecology if required. Therefore, we considered it was reasonable that Ms A was discharged back to the care of her GP. We did not uphold the complaint.

However, the adviser noted that the post-surgical verbal advice given to Ms A was not documented. Also, Ms A did not appear to receive any written advice as back up, even though she was still recovering from the anaesthetic when the verbal advice was given. We made some recommendations regarding this.

Recommendations

What we said should change to put things right in future:

• There should be a clear record of the verbal advice given to patients after surgery.
• In similar circumstances, consideration should be given to patients receiving written post-surgical advice to back up any verbal advice given to them.