Decision Report 201702715

  • Case ref:
  • Date:
    August 2018
  • Body:
    Tayside NHS Board
  • Sector:
  • Outcome:
    Some upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Miss C suffered ongoing complex urological problems (problems relating to the urinary tract, bladder or kidneys), and underwent a dilation and cystoscopy procedure (a procedure to look inside the bladder and stretch the urinary opening) at Ninewells Hospital. During the procedure biopsies (samples of tissue) were taken. Miss C complained about the medical and nursing care during this procedure, which she found very painful and distressing. Miss C also complained about her medical care following the procedure, and that it took several months for the board to refer on to a urological specialist in another board area after she requested this.

Medical and nursing staff met with Miss C to discuss her concerns. The board apologised for some aspects of the nursing care, and said the day-of-surgery admission pathway had not been suitable for Miss C, as it could not provide much of the support she required. Miss C was not satisfied with this response, and she brought her complaint to us.

We took independent advice from a consultant urologist and a nurse. We found that most of the medical care Miss C received was reasonable. However, the operation note was not sufficiently detailed to show why it was necessary to take biopsies, which caused Miss C post-operative pain. We upheld this aspect of Miss C's complaint.

In relation to the nursing care, we noted that the board had acknowledged certain aspects of care were staff could have acted differently and had taken action to discuss Miss C's concerns with staff. We considered these actions to be reasonable and found that the nursing care Miss C received was appropriate. We did not uphold this aspect of Miss C's complaint.

Finally, we found that there was a delay in referring Miss C to a specialist. We noted that some of the delay was due to her requiring urgent hospital admission in this period; however, part of the delay was due to a lack of cover arrangements during an unexpected staff absence. We upheld this aspect of Miss C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Miss C for the delay in referring her to a specialist and for the failure to document why the biopsies were necessary. The apology should meet the standards set out in the SPSO guidelines on apology available at

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

  • Operation notes should include sufficient detail to explain the clinical decisions taken during the operation.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: December 2, 2018