Medical history
14. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.
15. Miss R complains when she had the urgent colposcopy appointment at the Trust, the doctor seemed unfamiliar with her medical history. Miss R says the doctor had not read her notes and was not aware that she had been recently monitored and treated for endometriosis, despite being one of the listed clinicians on documents she had.
16. Miss R explained this caused her alarm and distress as she felt the doctor was not prepared for the appointment. We recognise this was an upsetting experience for her.
17. The Trust said it is usual for questions to be asked about the individual patient’s clinical history. It explained this is to make sure the information on the system is correct and to understand the patient’s situation in their own words.
18. We reviewed the medical records and found there was a brief summary for the reasons for referral.
19. We looked at Miss R’s account of what happened and the medical records and considered them against the GMC guidance.
20. GMC guidance explains the professional standards expected of a doctor. It says when assessing, diagnosing, or treating patients a doctor must, ‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.’
21. We recognise Miss R was alarmed by the doctor’s questions and appreciate it can be frustrating to repeat information to different clinicians. We think it is likely the doctor wanted to hear Miss R’s medical history in her own words, which is in line with GMC standards.
22. We understand Miss R’s concern that the doctor did not seem to be aware of her endometriosis despite being listed as a clinician on documents she had.
23. As an independent organisation, we must reach our own impartial decision based on the evidence we have. We have not seen any sign that the doctor did not know about Miss R’s recent treatment for endometriosis. We appreciate the discussion about her medical history during the appointment caused Miss R distress and we empathise with the situation she is in.
24. In summary, we think the Trust acted in line with GMC standards when asking Miss R questions about her medical history and we have seen no sign that anything went wrong in this part of her complaint.
Conduct
25. During the appointment on 15 August 2022, Miss R says the conduct of the doctor fell below expected standards. Miss R says they rushed through getting consent, did not talk her through the procedure, made concerning comments saying they ‘weren’t certain what it was they were seeing under the scope’ and told her off even though she was visibly distressed. She says the doctor became frustrated with her and said, ‘I’ve not cut you yet’.
26. We are sorry to hear about the intense emotional distress Miss R described.
27. The Trust said the doctor, ‘would like to sincerely apologise for the distress and upset caused’ during the appointment and they had reflected on Miss R’s experience to improve future communication with patients and to make sure they communicate in a more compassionate way.
28. The Trust acknowledged that Miss R was anxious about the colposcopy procedure. It said Miss R was offered Entonox (gas and air) as well as local anaesthetic to reduce pain and discomfort. It said the colposcopy team tried to reduce Miss R’s anxiety by talking to her throughout the procedure. The Trust said Miss R was offered the opportunity to have the colposcopy done under a general anaesthetic which she declined.
29. The Trust explained the procedure is typically a quick one that routinely takes two to five minutes to complete. It recognised this may have contributed to Miss R feeling it was rushed.
30. We considered Miss R’s account and the medical records. We do not think it is possible for us to reach a decision on this part of the complaint because there is no other evidence for us to look at. Details of what is said during a procedure are unlikely to be recorded. An investigation would not be practical and would not help us to reach a satisfactory conclusion for Miss R.
31. We can see the Trust apologised for this part of the complaint, which is in line with NHS complaint standards that state saying sorry is always the right thing to do, not an admission of liability and is the first step to learning from what happened to prevent it happening again.
32. While we do not doubt Miss R’s account, it is not possible to reach a decision on what the doctor intended to say and how this was received.
33. We are aware that Miss R’s partner was with her in the consultation room at the time. Miss R’s partner was behind the curtain when the procedure took place. Afterwards, Miss R says she discussed what happened with him.
34. We have considered whether this evidence helps us. We cannot consider Miss R’s partner’s account as independent because of their close relationship. That is not to say we do not believe them. It means this evidence would not be enough for us to make a firm decision.
35. We recognise complaints mean a lot to the people bringing them to us. As the last stage in the complaints process, we sometimes have to make difficult decisions.
36. In making our decision, we do not wish to dismiss what Miss R told us about her experience. We appreciate this response may not offer the closure Miss R wanted and we are sorry for any further distress this may cause. We are sorry we could not provide her with a more agreeable outcome.