Appointment on 30 July 2021
17. GMC guidance paragraph 15 states that doctors ‘must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary.’
18. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs that the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that the Trust got anything wrong.
19. Mr U’s records show he attended an outpatient appointment on 29 July 2021. Because of the severity of his hernia, the consultant surgeon advised him he would need to go to hospital for surgery the same weekend.
20. On 30 July, Mr U’s planned operation was cancelled because he had chest pain. The Trust told him he would need to have no chest pain for the next 24 hours for an operation to be reconsidered.
21. Mr U feels the Trust should not have cancelled the planned operation on 30 July 2021, as his hernia was so severe. He says his hernia became life-threatening and the pain was as though his whole stomach was about to burst open.
22. In its complaint response, the Trust explained Mr U developed severe chest pains, which he described as being much worse than his usual angina (chest pain caused by reduced blood flow to the heart muscles), during a preassessment with a consultant anaesthetist on 30 July.
23. The Trust explained they decided to postpone the operation because of this. It explained the consultant anaesthetist informed Mr U it would be reasonable to proceed with surgery provided he had no chest pain for 24 hours.
24. The Trust explained two other consultant surgeons and a consultant anaesthetist discussed his case and agreed it was not sensible to proceed with surgery so soon after severe chest pains for what was a P3 (procedures to be performed within three months) priority hernia.
25. In our adviser’s view, the consultant surgeon’s decision to not proceed with Mr U’s surgery following his chest pain was in line with GMC guidance.
26. As our adviser explained, to reduce the risks of a heart attack or other problems, it was safer to postpone Mr U’s surgery as this type of surgery can be complicated. This is because chest pain can be a symptom of heart disease.
27. NHS information explains patients like Mr U who are aged over 50 are more likely to have complications from this type of surgery and have another illness such as a heart disease (symptoms that include chest pain) or breathing problems. We consider the Trust’s decision to not operate, allow his chest pain to go and avoid any potential risks or complications was in line with GMC guidance, as it took account of his clinical history.
28. Mr U was first admitted to hospital on 29 July with a ‘complicated hernia in the right groin’. In line with FSSA guidelines, the surgical priority for this type of hernia is P1 (procedures to be performed within 24 hours).
29. Our adviser explained Mr U’s hernia had got smaller on its own by 30 July, and so surgery was no longer considered urgent. We can see from the records the hernia had reduced by the time of the appointment.
30. According to the FSSA, surgeries for hernias presenting with complications that have previously settled should be performed within three months.
31. Mr U’s surgical priority then changed from P1 (procedures to be performed within 24 hours) to P3 (procedures to be performed within 3 months). We consider the Trust acted in line with FSSA guidance in changing the priority of his surgery and not operating urgently.
32. Upon review of his medical record, the Trust’s response and advice from our adviser, we can see that the decision to not operate on Mr U on 30 July to avoid any potential risks appears to be in line with the relevant guidance.
72 hours ESAC access
33. As above, GMC guidance paragraph 15 states that doctors ‘must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
• promptly provide or arrange suitable advice, investigations, or treatment where necessary’.
34. Mr U explained a discharging consultant saw him on 31 July 2021 and advised he would be discharged with 72-hour open access to ESAC. But Mr U explained the Trust failed to follow through on its agreed service access to surgery from 30 July to 2 August if he had no chest pain for 24 hours.
35. Mr U explained he was anxious and concerned about this decision, as it offered him no protection against his serious health condition. He described how each day it caused him severe hernia, bowel and stomach pain.
36. As the Trust explained, ‘discharged with ESAC access for 72 hours’ does not mean patients can come back for an operation during this time. It means patients who are discharged do not have to go to accident and emergency during the 72-hour post-discharge period but can go straight to the surgical assessment clinic.
37. The Trust is part of the Surgical Ambulatory Emergency Care (SAEC) network, which is designed to support organisations to develop an SAEC service. Since joining the SAEC network, the Trust has merged its Surgical Ambulatory Unit and its Ambulatory Emergency Unit to form the ESAC.
38. The AEC guide explains the purpose of ESAC is to provide rapid assessments by ‘ensuring patients requiring emergency surgery are seen by senior surgical staff and have the same rapid access to diagnostic scans as inpatients’.
39. Mr U’s medical record shows he was advised to seek medical attention if his hernia reappeared and became painful and did not return to its normal size. We have not seen any information in his medical record showing he used the 72-hour ESAC access after discharge or asked for medical attention during this time.
40. The decision to discharge him with this ESAC access option shows it was to ensure he could be assessed as quickly as possible if urgent surgery was needed. We consider this is in line with the GMC guidance, as the Trust ensured he had an option for quick investigation and treatment if he had complications after discharge.
Elective list and follow up/no action for 20 days
41. Our Principles say: ‘where a public body has failed to get it right and this has led to injustice or hardship, it should take steps to put things right […]in many cases, a prompt explanation and an apology will be a sufficient and appropriate response.’
42. Mr U said he could not understand why he would be put back on a waiting list when the consultant had already accepted that he needed surgery urgently. He said he was advised to wait for a period of 24 hours without chest pain, not to go home with a serious ‘complicated hernia’.
43. Mr U said he was unaware of how early an ‘early elective list’ was. He was still concerned and anxious as his pain was worsening and affecting his mobility. He explained this situation did not help him as he has long-term depression and anxiety, which increases his anxiety levels and brings on his chest pain, which the Trust should have considered.
44. Mr U said that, because he had not heard from the Trust five days after discharge, he called the Colorectal Coordinator Support team. They said they would contact the consultant surgeon for a surgery date. Mr U did not understand why the consultant surgeon did not follow up on his situation, given that he had admitted him for an operation and taken responsibility for his care.
45. As the Trust explained, Mr U’s surgery was booked in line with its clinical urgency (surgical priority P3). The change in priority was in line with FSSA and GMC guidance. The Trust explained this was superseded when he was admitted on 16 August 2021 with ‘small bowel obstruction’ (something blocking the intestine) caused by ‘strangulation of his hernia’ (when the muscle around the hernia has become tight, the blood supply to the tissue inside the hernia is cut off).
46. As the Trust explained, based on the recorded information from Mr U’s admission to hospital on 30 July, his surgery was not clinically urgent. All surgical procedures must be assessed to decide which ones are the most serious and scheduled around cancer/life-threatening surgeries.
47. Mr U’s account suggests he went home on 30 July thinking he could still have surgery within 24 hours provided he had no chest pain, but this arrangement changed soon afterwards because the priority of his hernia was changed from P1 to P3.
48. Two days later, the Trust told Mr U’s GP about his discharge and the change in priority. Although the Trust informed Mr U’s GP within two days of its decision, it should have communicated this with Mr U too, as it is good practice to communicate changes in treatment to patients (GMC guidance, paragraph 32).
49. We can see the Trust has apologised for the service Mr U received and the lack of communication he experienced from its team. The Trust has assured Mr U its team saw all the information about his surgery and admissions and he stayed on the waiting list until his emergency admission on 16 August.
50. We understand Mr U likely experienced distress and confusion when the Trust told him his surgery would be postponed, and when he did not hear from the Trust for some time after.
51. We can see the Trust has already apologised for its poor communication and clearly explained in its responses the reasons behind putting Mr U on a waiting list.
52. We consider this is a proportionate remedy to the distress Mr U experienced, in line with our Principles.
53. We understand the Trust has also explained this to the team responsible by reminding them of their responsibilities to communicate effectively. This again shows the Trust has tried to put things right, which is in line with our Principles.
54. We recognise Mr U’s frustration and confusion because of what has happened, and we are sorry to hear about his distressing experience.