Dorsal Slit procedure
16. Mr H says that the Trust did not appropriately inform him of the risks of the dorsal slit procedure. Specifically, he says that the Trust did not tell him that the procedure could affect the functionality and appearance of his penis.
17. In its response, the Trust said if Mr H had not consented to the procedure, he might have suffered from penile gangrene, which is death of body tissue due to either a lack of blood flow or a serious bacterial infection.
18. The Trust said that given the acute clinical situation Mr H was in, it needed to perform the dorsal slit in order to access the glans penis. The Trust said it had a discussion with the Consultant Urological Surgeon from the other Trust. They advised that it might be possible to reverse the dorsal slit, but the foreskin could end up tight due to the previous penile glans injury that occurred in 2017/18.
19. In order to establish whether the consent form Mr H signed was appropriate, and whether the decision to perform the dorsal slit was necessary, we looked at Mr H’s medical records and sought clinical advice from a Consultant Urologist.
20. A patient leaflet from the British Association of Urological Surgeons (BAUS) is relevant here. This specifically mentions that the cosmetic appearance, after the dorsal slit procedure, is not as good as it would be with a circumcision, and that between 1 in 10 and 1 in 50 patients experience dissatisfaction with the cosmetic result.
21. Loss of sensitivity is not necessarily mentioned within the BAUS guidance, and as the Trust have explained, the loss of sensitivity may also be explained due to Mr H’s previous visits to the hospital due to harm to his penis.
22. We can see from the consent form signed by Mr H on 18 June, the mentioned risks include: ‘infection, bleeding, pain, failure, injury to surrounding structures, erectile dysfunction.’ There is no reference to the potential cosmetic dissatisfaction. This is a failing as the damage to the appearance of Mr H’s penis should have been discussed with him.
23. In addition to this, the General Medical Council (GMC) guidance on communication states that a doctor: ‘must give patients the information they want or need to know in a way they can understand.’ Mr H would need to have known about the potential cosmetic dissatisfaction that may occur following a dorsal slit procedure.
24. As we have identified a failing, we looked at the impact. Mr H says that if he was made aware of the effect this procedure could have on the appearance and function of his penis, then he would not have signed the consent form. Mr H says that this experience left him feeling angry about how he was treated and cared for. Since the surgery, Mr H says that he has been left strongly dissatisfied with the appearance of his penis, and he feels he has been prevented from having a better clinical outcome.
25. This has clearly been an incredibly difficult time for Mr H, and we appreciate that this situation has had a significant impact on him. We sought clinical advice about what would have happened if Mr H had not had the surgery, and if there were other potential options available to him.
26. Our adviser explained that if Mr H had not had this operation, then he would have remained in pain, and his entire penis would have become scarred and fibrotic. They added that observation was an alternative but is not recommended.
27. They highlighted guidance from the European Association of Urology – Guidelines on Priapism 2015 is relevant here. This states that a Priapism lasting more than 36 hours at presentation would be best treated with a penile prosthesis. If Mr H was observed, rather than operated on, then this would have created a higher risk and chance of complications for the penile prosthesis procedure. We can see that the Consultant Urologist at the Trust explained this to Mr H in its complaint response.
28. Another alternative would have been acute circumcision (removal of the foreskin), which we can see was listed as a possibility in the consent form signed by Mr H. However, our adviser has explained that this offers a less acceptable cosmetic outcome than a dorsal slit, or future circumcision in an elective setting. The choice of a dorsal slit procedure would therefore be the best choice.
29. In their complaint responses the Trust highlighted that the loss of sensitivity suffered by Mr H might be due to previous penile glans injuries in 2017 and 2018. We discussed with our adviser who said that whilst there is no specific guidance here, the Trusts response was reasonable, as this could account for the loss of sensitivity.
30. We have identified failings with the consent form signed by Mr H; however, we cannot say this is reason for his entire claimed impact. This is because the dorsal slit procedure was necessary, and Mr H would have had a worse clinical outcome if this procedure did not take place. However, Mr H does say that he feels angry about not being fully informed. Even though this procedure was his only option, he missed the opportunity to make an informed decision about this. We will consider the remedy for this impact in the as recommendations part of the report.
Transfer to different hospital
31. Mr H says that the Trust informed him that he would need to be transferred to a different hospital for urgent further treatment. Mr H was under the impression he would be transferred to a London Trust specialising in penile prosthesis surgery.
32. In its response to the complaint, the Trust said that when Mr H woke up from Surgery on 18 June, the priapism had been successfully deflated. However, the following morning the priapism had recurred, and at this point advice was sought from a consultant at a different hospital in Southampton. This consultant suggested that Mr H could be transferred to London Trust where they also worked.
33. The Trust then say, following contact with the London Trust, it was suggested that rather than transfer Mr H to London, he should be managed locally, and that the consultant could see him in Southampton the following week. The Trust also say in this response that as it was now over 36 hours since the onset of the priapism, there was nothing to be gained by further acute intervention.
34. We looked at Mr H’s medical records and found entries that relate to this situation. The records show that Mr H was informed that he would be transferred to the London Trust, where the consultant was waiting for him, and that they may be able to fit him into their surgery list on Friday for further treatment. However, it would appear this was communicated to Mr H before it had been formally discussed and confirmed with either the consultant, or the London Trust.
35. The entry from later that same day shows that the London Trust had declined the transfer, and that the consultant had changed his mind, concluding that Mr H would be managed best if he was kept locally. The records show that there was a delay in informing Mr H of this of around 45 minutes.
36. The records show that Mr H was angry and upset about this situation as he believed he was going to be transferred, and as such had been kept nil by mouth. The records also show that the Trust apologised for the miscommunication, and for the delay in informing him of what had happened. This apology is reiterated in their complaint response.
37. In order to establish whether Mr H needed to be transferred, and if his clinical management was appropriate, we sought advice from our clinical adviser. Our adviser explained that there was no need for Mr H to be transferred, and that additional surgery would have caused a number of risks. Our adviser explained that the usual course of action would be for Mr H to return in around 3 weeks’ time (although this could be even 4 to 6 weeks, which is still considered acceptable).
38. Guidance from European Association of Urology – Guidelines on Priapism 2015 says that a Priapism lasting more than 36 hours at presentation would be best served with a penile prosthesis, meaning that Mr H would likely need a penile prosthesis. However, this could not be performed until Mr H had recovered from the first surgery. To transfer a patient and insert a penile prosthesis, after both aspiration and shunt surgery, would pose far too great an infection risk to the implant, and would therefore not be recommended.
39. Our adviser explained that there is no specific guidance relating to this, but the usual course of action is for the patient to first recover from the initial surgery. Then an appointment can be booked to insert a penile prosthesis. A circumcision can then be considered electively.
40. Based on the evidence available, a failing did not occur here. There was no need for Mr H to be transferred to a different hospital, and the management of his condition was in line with the relevant medical guidelines (as explained above).
41. We do acknowledge, however, that this was not communicated in the best way to Mr H, and that it must have been frustrating to be told that you would be transferred and kept nil by mouth, to then be told that you would not be transferred.
42. This was made additionally frustrating as there was a delay in explaining this to Mr H. We again considered this, alongside the GMC guidance on communication (referenced earlier in this report). We can see that Mr H was informed and kept up to date with what was happening with his care. We recognise that there were some shortcomings in communication but overall, the Trust acted in line with the GMC guidance.
43. We are also pleased to note that at the time of his treatment, and during the complaints process, the Trust apologised to Mr H. Based on this, we have found no failings with this part of the complaint.
Pain relief not given with penile block
44. Mr H complains that he was not given any pain relief prior to receiving a penile block. The penile block was injected whilst Mr H’s penis was swollen, and he was in a lot of pain. Mr H believes he should have received some form of pain relief, or Entonox (gas and air), whilst this procedure was carried out.
45. The Trust say in their complaint response that Mr H was given pain relief as well as the specific penile pain relief in the form of the penile block.
46. In order to establish whether Mr H should have received pain relief, or Entonox, prior to receiving the penile block, we looked at his medical records and sought advice from our clinical adviser.
47. Mr H’s records from 19 June record ‘Penile Block for pain control’. There is no other mention of pain relief to be given at this time. We are aware from Mr H’s records that he was receiving other pain relief medication as part of his post-operative care.
48. We discussed this with our clinical adviser. They explained that there is no specific guidance that would be relevant here, but there is a uniform opinion of any clinician in this situation. They added that a penile block does not require pain relief or Entonox. The penile block is there to block the nerves to the penis, and so is in itself pain relief. The actual administering of the penile block may cause pain, but only in as much as any injection would cause pain.
49. We appreciate that this procedure was painful for Mr H, and that he felt he may have been more comfortable with additional pain relief. However, there is nothing to indicate that additional pain relief was required prior to the penile block being injected, particularly as the penile block would be considered pain relief itself. Therefore, there are no failings for this part of the complaint.