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A medical practice in the Nottinghamshire area

P-001431 · Statement · Decision date: 28 June 2022
Complaint (AI summary)
Mr O complained a medical practice failed to follow proper infection control when removing sutures from his shoulder, leading to an infection, further surgery, and life-changing injuries.
Outcome (AI summary)
Closed. The complaint was outside the one-year time limit for investigation, and no justification was provided to set this time limit aside.

Full decision details

The Complaint

3. Mr O complains that infection control procedures were not properly followed when sutures covering his shoulder surgery site were removed at the Practice in June 2019.

4. Mr O says this led to him getting an infection in the surgery site, leading to further surgery and the removal of his shoulder tendons. Mr O says he has life changing injuries and there has been significant psychological impact to him.

5. As outcomes, Mr O would like an apology, service improvements, and financial compensation.

Background

6. Mr O had shoulder surgery in May 2019.

7. In June 2019, Mr O attended the Practice to have the sutures on his shoulder removed.

8. Mr O was seen at the Practice in June 2019 and early infection was noted in his shoulder.

9. Two days after his visit to the Practice, Mr O spoke to 111 as the shoulder surgery site had worsened. He attended the hospital where the surgery was performed, and he was treated for an infection.

Findings

11. Our legislation, the Health Service Commissioners Act 1993, states a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year unless we consider there is a good reason to do so. We have discussed this with Mr O to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to Mr O.

12. Mr O attended the Practice in June 2019 for his sutures to be removed. He first raised concerns about a possible infection three days later, but the infection was not confirmed for a further two days. However, Mr O did not know at this point whether it was the surgery or the actions of the Practice that caused the infection. The hospital who conducted the surgery completed an incident investigation which suggested the infection was caused at the Practice. This was shared with Mr O in around September 2019.

13. Mr O provided an email from the Practice dated September 2019. In the email, the Practice acknowledged Mr O’s statement about whether the nurse who removed his sutures was wearing gloves, and that suture removal learning could be put in place. It also references pictures of Mr O’s infected wound and the impact of the infection. This supports the view that Mr O was aware of the issues in September 2019. He therefore had to bring the complaint to us by September 2020.

14. Mr O said in his September 2021 complaint form to us, that in 2019 he did not fully understand the importance and requirement for sterile management of surgical wounds. He said he only recently became aware of this, which prompted his September 2021 complaint. Point 2.238 of our Service Model Guidance states: ‘A complainant may be aware of an issue at the time, but not experience a serious impact until a later date. For example, a complainant receives poor dental treatment that leaves them in a lot of pain, but they do not raise a complaint about this until several months later when the pain leads to a serious gum infection. In this instance the date of the initial dental treatment would usually be when the complainant had notice to complain. Not when the injustice became serious enough, they decided to complain about it.’

15. We appreciate learning this new information must have been distressing for Mr O. Although this heightened his worries about the actions of the Practice, as per our service model guidance, we cannot say this is when he became aware of the problems he experienced.

16. Mr O explained he was unable to bring his complaint to us sooner as he was undergoing further surgery and physiotherapy. He says the problems he experienced have been life changing and he has been adjusting to this. After listening to his account, it is clear the infection had a huge impact on his life, and we recognise it has been very difficult for him. While not wishing to diminish this, the above timeline shows Mr O raised concerns with the Practice in September 2019, therefore, it is likely he could have come to us sooner.

17. We also considered the time taken for the Practice to answer his complaint. The Practice said it responded to Mr O in September 2019. Therefore, this did not have a significant impact on his ability to bring the complaint to us.

18. Based on the above, it is clear Mr O was aware of the issues in September 2019. Unfortunately, the complaint was not brought to us until September 2021, one year outside of our time limit. While not dismissing the impact of the issues on Mr O, we consider he could have come to us sooner. Therefore, we will not consider this complaint further.

Our Decision

1. We have carefully considered Mr O’s complaint about a medical practice in the Nottinghamshire area (the Practice). We decided the complaint falls outside of our time limit.

2. Mr O complains the Practice did not properly follow infection control procedures when it removed the sutures from his shoulder in June 2019. While we do not want to diminish the lasting impact these events had on Mr O, we consider he could have brought his complaint to us sooner. We have therefore decided the complaint falls outside of our time limit.