Significant failings in administration and complaint handling

What happened

Miss H had surgery to remove an ovarian cyst. The Trust scheduled the surgery for a morning, but it was delayed because the surgical team did not have her medical records.

Miss H also found the attitude of some of the clinical staff to be inappropriate. A small cyst recurred since the surgery, so she queried whether the procedure was carried out appropriately.

Miss H also had follow‑up care at the Trust. She received letters from the Trust that showed two different hospital numbers, but although she raised this with the Trust, it delayed correcting it. Miss H had other administrative problems during this period.

After this, Miss H's GP told her that he had not had adequate information about her procedure from the Trust. She also found out that records were missing from her medical notes.

Miss H complained to the Trust. There were a number of delays throughout this process and Miss H did not feel that the responses she received were robust.

What we found

Miss H's surgical procedure was carried out appropriately. These types of cysts can recur and this does not mean that there were errors in the original surgery. We also consider that the Trust addressed Miss H's complaint about staff attitude appropriately.

However, there were repeated administrative and record‑keeping failures by the gynaecology department throughout Miss H's time at the Trust.

The Trust's responses to Miss H's complaints fell very far short of an adequate standard, and there were unreasonable delays in responding to her complaints. These concerns have arisen in previous investigations about this Trust, so we considered that there was evidence of systemic problems here.

Putting it right

The Trust agreed to apologise to Miss H for its failings. It also said it would review its handling of her complaint to establish a reason for the delays and poor responses; audit its complaint handling, looking at both the timeliness of complaint responses and the standard of the responses; identify how it could improve its complaint process after the audit; and consider how it would monitor the standard of complaint handling.

It also agreed to review administrative and record‑keeping procedures in the gynaecology department to find out why the repeated failures occurred, and identify appropriate improvements in an action plan.