Manchester University NHS Foundation Trust

6. Miss A complains about Manchester University NHS Foundation Trust (the Trust): • on 3 December left her with skin damage on her front and back following surgery on her right shoulder; and • did not tell her about the skin damage at the time.

7. Miss A says her skin was left burnt and blistered. She says the injuries are still visible on her skin and that she could be left scarred.

8. Miss A wants an apology, full explanation as to why it happened as she does not believe it was an allergic reaction. She also wants service improvements and financial remedy.

9. The following is a brief background to put the complaint into context. We have not provided all the details as both parties are aware of the circumstances of the complaint.

10. On 3 December 2019, Miss A had capsule release surgery on her right shoulder due to a frozen shoulder. This is keyhole surgery involving the release of a tight capsule.

11. On 4 December, Miss A developed an itch. When she took off the dressing, she noticed leaking white fluid. She also had blisters on her front and back.

15. Miss A says following surgery she was left with skin damage on her front and back. She says the Trust did not tell her about the skin damage at the time.

16. The Trust said Miss A’s skin damage was due to an allergic reaction to the mefix tape. Mefix is a dressing retention tape which will securely stick dressings to the skin and is formulated to avoid any skin irritation. The Trust also say there is no documentation to say that Miss A was burnt during surgery.

17. The medical records support what the Trust has said. There is no note in the records to say Miss A’s skin was damaged during surgery. Our surgeon adviser has said a radio frequency probe (RFP) is used during the procedure.

18. Case study suggests, on rare occasions publications have shown dermal burns of patients due to hot water spilling from the RF.

19. Having reviewed the photographs of the wound provided by Miss A, our dermatologist adviser has said it does not look like allergic reaction. This is because the wound is the wrong shape and does not reflect the outline of a tape mark. Our dermatologist adviser said a tape mark would be straight edged and square. Miss A’s wound is an arch shape and suggests some other kind of cause.

20. Our dermatologist adviser has said not many things would cause this type of wound other than a spillage or piece of electric equipment.

21. Furthermore, it is extremely rare for mefix tape to cause an allergic reaction. A testing report in the last 10 years shows that there have been no cases of allergic reaction found in the adhesive used in mefix tape.

22. We recognise the Trust dispute this and say Miss A’s skin was not damaged using the RFP. The Trust believe Miss A had an allergic reaction and was not burnt during the procedure. Our dermatologist adviser has said for the Trust to prove it was allergic reaction it would need to take carry out a formal patch test. This has not been done.

23. The evidence suggests on balance Miss A’s skin was damaged during surgery. While we understand the Trust dispute this, there is no evidence to support the view it was an allergic reaction. Given fluid can spill from the RFP and the information in the case study, it is unlikely that mefix tape would have caused the damage. We understand Miss A’s concern that she was not informed there was damage to her skin. While the evidence suggests her skin was damaged, it appears the Trust were not aware of this at the time. Therefore, they would have be unable to tell her. We consider causing the damage and not being aware of it is a failing.

24. When we identify failings, we need to establish the weather this had an impact on the complainant.

25. Miss A says her skin was left burnt and blistered. She says the injuries are still visible on her skin and that she could be left scarred.

26. We asked our dermatologist adviser what the likelihood is that Miss A could be left scarred. Our dermatologist adviser has said it is not clear whether the wounds will leave long term scars.

27. Based on the evidence and given the nature and size of the wound we are unable to say that she could be left with long term scars.

28. We acknowledge Miss A was left burnt and blistered and this would have been distressing for her. Miss A says she is diabetic and so this would mean that her healing may have been longer than for other people. It is likely the blisters would have been uncomfortable for her during the healing process.

1. Miss A complains she was left with skin damage following surgery. She also complains the Trust did not tell her about the damage at the time. We understand the events that caused Miss A to complain about our very important to her and the impact the events had on her.

2. We understand it was worrying for Miss A so see the damage on her skin when she removed the dressing. We found evidence her skin was damaged during surgery. This is because there is no evidence to support it was an allergic reaction. We can say Miss A’s skin was burnt and blistered. However, we cannot say that she could be left scarred.

3. We understand communication is important and that Miss A says the Trust did not tell her about the skin damage at the time. There is no evidence the Trust knew about the skin damage, therefore, they could not have told her.

4. We therefore partly uphold the complaint.

5. We recommend the Trust apologise to Miss A and share service improvements it will make so this does not happen again. We also recommend the Trust pay Miss A £200 for the injuries caused to her skin.

29. In considering our recommendations, we have referred to our Principles for Remedy. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

30. In line with this, we would recommend the Trust apologises to Miss A for the skin damaged caused during surgery.

31. Our Principles say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they does not repeat maladministration or poor service. In line with this, we recommend the Trust share with Miss A what service improvements it will make so that this does not happen again.

32. Our principles state that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

33. To determine a level of financial remedy, we review similar cases where similar injustice has arisen, along with our severity of injustice scale. Following this review, our current thinking is the organisation should pay £200 in recognition of the minor injuries caused.

34. We ask the Trust carry out these recommendations within one month of the date of this final report.