Decision following the review of your complaint.
I am pleased to say that I havenow completed my review of your complaint and i am writting to tell you my decision. I am also sending a copy of this letter to ................................... , the acting chief executive at ......................................................(the trust).
I have decided notto uphold your complaint. This is because I consider that the trust has taken appropiate action to resolve your complaint. Therefore , I am not making any reccomendations for further work to be carried out.
During my review , I have considered the complaints file and the healthcare records that I haverecieved from the trust. , as well as the information you have provided. I have also taken advice from an independant clinical advisor., .......................... who is a consultant obsetrition and gynaecologist with relevent expertise.
You wrote to .............The trusst on 15 may 2008 to complain about the maner i which you were treated in hospital. You explained in great detail the sad events of your miscarriage that led to your coplaint.
Summary of the trusts response.
The trust wrote to you on 20 may 2008 to acknowledge your complaint. The trust stated you had confirmed in a telephone conversation that you had agreed fpr your complaint to be handled by ........................... matron for gynaecology services.
You recieved a formal response on 3 J une 2008. The trust offered its condolences toyou and accepted it had been a distressing and traumatic time for you. The trust also apologised for the delay in responding to you .. T he trust said that due to a number of resaons ....... could not assist with the investigation.
You remained unhappy with the response so the trust arranged a meeting with you with a view to resolving your complaint. You met with ...... and ............ consultant , on 16 june 2008. Another meeting was arranged for 14th august 2008 with yourself ............. and your ICAS advocate , who also made notes for the meeting.
I have considred below the issues you askede us to look at.
1: Delay in the accident and emergency department (A&E)
You explained that you had been suffering pains and bleeding for approximatly 23 hours. When you attended A&E you were told to sit and wait for someone. You explained thatin your wait you soiled your trousers , and that you were also passing small blood clots. You said that when you approached the "desk" you were told to go to the nurses station to seek assistance. You explained at this point you wentinto shock as you began to realise the reality of what was happening. You explaied you had spoke to a nurse who arrangd for you to be transferred to "resuss" .
The trust said that A&E obviously isnt the ideal enviroment for you to be seen in. The trust explained that ideally , you would have beentransferred straight yo the gynaecology ward. The trust said that it was aware of the importance of sensitivity and privacy. The trust explainedthat when you atteneded A&E there were no available beds in the gynaecology ward. The trust hadexplained it had taken steps to address this by designating a room on the mccallum ward for women who may be miscarrying . The trust agreed it was unacceptable that you were not prioritised for immediate attention and apologised for this. The trust said that this practise would become part of the performance management in A&E . The trust said that it would confirm when the plan to have the designated room was complete.
When the trust forwarded the information to the healthcare commission it said that changes have been made in that women who are miscarrying are prioritised by both reception saff and the gynaecology team.
I asked the clinical advisor for his comments regarding this issue. The advisor is of the opinion the response was adequarte and appropiate. The advisor notes the ere major alterations were going on in A&E at the time which may have caused problems and delays.The advisor also notes that the trust has apologised for the situation and has explained that it has now improoved facilities for misarryng patients. The advisor says the action taken to improove is appropiate.
Decision.
When reviewing a complaint it is always reassuring to note when a mistake has been recognised and apologised for.It is also reassuringto note that the trust has takenn action to prevent a recurrence of simular events. Both the clinical advisor and i hae noted the action taken , and its considered that this action is appropiate. Withthis in imnd i will not ask for further work to be carried out.
2: Inappropiate comments.
You explained that after were moved to the resussitation area a doctor told you things would be "OK", as it " was only a miscarriage" . .
The trust sid thatconfirmed that you were seen by .................................... , who denied saying "it was only a miscarriage".
Your ICAS advocate forwarded your indeoendant review form to the healthcare commission on 6 october 2008.
Decision.
From reviewing thetwo accounts of these events it is clear that there are differances between your version of events and those of the trust. In absence of an independant third party witness to corrobrate either version of events , you will apprieciate that it is hard for me to pass comment.The reviewof your complaint is based on the information provided by yourself and the trust.Therefore without the existance of any statement by an independant third party witness i am unable to support either versions of events. Withthis in mindi will not be asking the trust to carry out any furthrer work..
3. Specimen jar and foetus remains.
You explained after you had miscarried, you were given a jar containing a urine sample , taken from when you used the commode. You described ohow the jar also contained blood clots which , you were told , were the foetus. You expressed deep concern over how insensitive this had been , that the doctor had acted cruelly. You explained that you were left with your partner what you had been told . You said that the nurse took the sample and showed it to your partner you told the trust you wanted a personal apology from the dr in question.
The trust explained the jar was taken to the room as the doctor was unsure where would be the safest place to leave it, as she was unfarmilliar with the correct procedure to follow.The trust accepted that this was wrong and acknowledged the severe distress this caused. The trust apologised for thisand said that this had beeen discussed in detail with the doctor.
The trust explained that it is normal practice for such samples to be taken away and labelled as a sensitive specimen , The laboratory would then confirm that the jar contained conception remains,which would be sent 1 month later to tirquay crematorium. The trust sais this is usually discussed with parents , and it apologised that this did not happen in this case. The trust said that this had been identtified to be raised at the doctors next training session at the team meeting.The trust said that this will ensure all staffwill be reminded of the correct procedure and of how important it is to be sensitive to parents suffering miscarriage.
The trust confirmed that the histopathology laboratory confirmed that your specimen contained the gestation sac and placenta . The trustexplainedthat on the 1st may 2008 you had a scan that showed the foetus legnth to be 9mm.
The trust said that you , and not the nurse or doctor , had shown the specimen to your partner,
The trust told you the doctor was extreemly sorry for the anxiety and distress she has caused. The rust saidthat it was unableto discipline a member of staff for a first mistake unless te mistake is seriousenough to warrant a formal warning. The trust confirmed that this issue had been discussed with the doctor at a poor performance review.
I askedthe clinical advisor for his comments regarding this issue . T he addviser confirms that the histology report shows no foetus was present in the sample. The advisor is of the opinion that there is clearly a differance in yours and the trusts version of the events regarding the handling of the specimen pot.
The advisor notes the trust accepted that the actions of the doctor were not appropiate , and apologised for this happening. The advisor notes the trust had explained the doctor was new to the unit at the time.
Decision.
I appriciate how upsetting and distressing this course of events was for you. As i explained in the first issue , when reviewing complaints the healthcare commission looks for signs of the trusts recognition of the short fall , an apology , and how it has learnt. . Both the clinical advisor and myself have noted that the trust has apologised for this issue. The trust has also detailed what action it has taken in response to this with a view to preventing a reacurrance . Therefore , with this in mind i will not be asking the trust to catrrry out further work.
Complaints handlig - lack of telephone logs .
You told the trust you had been trying to make a complaint. You were told you could not make a complaint as you had "only seen clots" . you said you felt as though you had not been believed.
At the second meeting it was raised that the complaints service had not been useful to you in raising your concerns.Yoou said that you contacted the patient advice and liason service who transferred you to .................... who then told you you could not make a complaint.
The trust said that there was no recollection of this call and it had been unable to locate any notes about the call. The trust said it would discuss the issue with PALS .
When the trust forwarded the information to the healthcare commission it stated youwere told you could not make a complaint as this was not in line with the trusts complaints procedure.
Decision.
From reviewing the complaints file i have noted you had been in contact with the trust prior to your letter of 15th may 2008. I understand that you had been expecting a telephone call on 15tth or 16th may 2008 from .................................... to discuss your complaint. However this telephone conversation does not appear to have taken place and i understand this is why you wrote to the trust.
I have been unable to find any evidewnce of any telephone conversations before 15thy may 2008 . The complaints file begins with your first letter.In our experience , we would expect a complaints file to always start with the record of a complaint be it writen ore orally.
I apprieciate that you may have made attempts to raise your complaint prior to writting your letter. However as mentioned in the second issue , the trusts version of the events differs from yours. Again, as previously mentioned , without an independent third party witness to corrobrate either version of events , it is difficultto make any further cooment on this issue. However the trust did refer to it s complaints procedure in it response, and it may be useful for you to have a copy of its procedure . Therefore , i would like to suggestthat the trust forwards you a copy of the trusts complaints procedure .
This concludes the independant review of your complaint.
Member » 
11:31
19 Visits
dont want to ruin it. My advocate rang meyesterday after she heard i was feeling very angry and upset . I told her the trust basically crushed everything i put to thehealthcare commission. She said not to worry as i do have a witness at the last meeting . So she said not to worry about it for the momentand dont let it ruin christmas and in the new year she will do a draft to it all and send me a copy and if im happy with it it will be going to parliamentary and health service ombudsman and the truth will also be told to the commission. 
