TWOC procedure on 7 September 2019
20. Mr A complains the Trust hastily carried out a TWOC procedure without a bladder ultrasound scan on 7 September 2019 and discharged him on the same day. He says the Trust ignored his existing sensitivities and other urological issues.
21. The Trust’s complaint response says it completed the TWOC procedure correctly. It says Mr A did not have any problems or discomfort when it discharged him, and he had passed 400ml of urine in two voids before he was sent home. The Trust says it is common practice to discharge a patient on the day of a TWOC procedure, and nurses with relevant TWOC training, not TWOC technicians, carried out the procedure.
22. The BAUS TWOC guidance says once catheters are removed, nurses or doctors ‘will examine [the patient] regularly, measure any urine [they] pass, and scan [their] bladder to see how much urine [they] leave behind after [they] urinate’. It goes on to say a patient would normally need to stay in hospital until they have passed urine satisfactorily.
23. Our nursing adviser says the clinical notes do not show when the Trust carried out the TWOC procedure, the post-TWOC void volumes or the bladder scan volumes. We have asked the Trust to give us notes of the TWOC procedure. However, it has only given us a clinical note confirming Mr A had passed urine before the Trust discharged him from hospital. As such, our nursing adviser cannot comment in detail on whether the Trust carried out the procedure in line with the guidance.
24. We can see from the BAUS TWOC guidance the Trust should have carried out a bladder scan following the TWOC procedure. Our nursing adviser says this would have enabled the Trust to identify whether the bladder was functioning independently or not. They say if a post-TWOC bladder scan showed a residual volume of more than 150ml, the TWOC procedure would have been considered a failure and Mr A’s bladder would probably have needed re-catheterising.
25. The BAUS TWOC guidance also says the Trust should have examined Mr A regularly and measured any urine he passed. There is nothing in the records we have seen to show the Trust did this. The Trust’s complaint response says there is no note of Mr A experiencing problems or discomfort, and he had passed 400ml of urine in two voids. It is not clear from the evidence we have seen where this information has come from.
26. The Trust has not followed the BAUS TWOC guidance here. So, there are failings in the way the Trust carried out Mr A’s TWOC procedure.
27. Mr A says the incorrect TWOC procedure led to him experiencing urinary retention soon after, which was extremely painful. In the Trust’s response of 5 March 2020, it says when Mr A saw the orthopaedic senior house officer, they explained re catheterisation can be necessary after the initial catheter insertion and TWOC procedure. The Trust says this does not show the initial TWOC procedure was unsuccessful.
28. Our urology and nursing advisers say a bladder scan after the TWOC procedure would not have prevented Mr A experiencing urinary retention.
29. Both advisers accept there is always a risk of urinary retention after the removal of a catheter. It is also important to note Mr A was at high risk of urinary retention as he had a history of urological issues, including previous urinary retention. This can be seen in the admission notes.
30. As the bladder scan did not happen, we do not know what residual levels were left in Mr A’s bladder and whether the levels suggested a successful or failed TWOC procedure. The lack of a bladder scan was a missed opportunity to potentially identify Mr A’s urinary retention.
31. Our nursing adviser says if the Trust had carried out a post-void bladder scan and identified Mr A’s urinary retention, his bladder could have been re-catheterised sooner. This may have prevented or reduced his discomfort.
32. Similarly, we cannot say Mr A’s difficulties would have been avoided had the Trust correctly conducted the TWOC procedure. However, he may have been reassured the Trust had done all they could.
33. Overall, we cannot say Mr A’s urinary retention was preventable as there are many factors involved. However, there is still the issue of Mr A not having a bladder scan after his TWOC procedure to assess the levels of residual urine in his bladder. He may have been reassured had a scan taken place, regardless of the outcome, and there was a missed opportunity to potentially identify he was experiencing urinary retention.
34. We set out our recommendations to the Trust later in the report.
Arranging a second TWOC procedure
35. Mr A says there were several delays and administrative errors when he tried to arrange a TWOC appointment and the removal of a catheter with the Trust. (Another NHS trust had fitted a catheter on 8 September 2019.)
36. The Trust says when a patient goes to an NHS trust for urine retention and catheter insertion, it is usual for that same trust to continue and complete the treatment. So, when Mr A contacted the Trust to arrange a TWOC appointment, the Trust treated it as a new referral as it had not seen him for urinary issues before. The Trust says appointments for new patients should come via a referral from a GP or another trust if it is for a new issue which the initial trust has not begun to treat.
37. We think it would be useful to outline what should happen about referrals to give some context.
38. Section 15b of the GMC guidance says doctors ‘must refer a patient to another practitioner when this serves this patient’s needs’.
39. Our adviser says the other trust treating Mr A would have given emergency treatment only and would usually advise the patient to contact their local services for any follow-up care.
40. There are notes of a phone conversation between Mr A and the senior house officer (SHO) on an orthopaedic ward on 10 September. These notes say Mr A felt the Trust discharged him too early without scanning his bladder. So, he said, the Trust should arrange a TWOC procedure on the same day as his follow-up appointment for his foot surgery.
41. The SHO said it is routinely the responsibility of the hospital who reinserted the catheter to arrange the TWOC procedure and follow-up appointment. They said if Mr A was not able to arrange a TWOC appointment where he was staying (away from home), then he should contact his GP to arrange this. A referral from his GP would contain his up-to-date medical information.
42. The SHO also said an orthopaedic ward would not routinely refer patients the Trust had discharged for TWOC procedures as they are no longer inpatients under the Trust’s care. Patients are referred back to their GP.
43. Mr A still felt it was the Trust’s responsibility. So, the SHO advised him they would fill out a form used for inpatients (on the orthopaedic ward) to try and arrange a TWOC appointment for him. However, they told Mr A he should still contact his GP.
44. The advice given to Mr A at this point is in line with what our adviser says. It is also in line with the GMC guidance as the SHO referred Mr A’s request for a TWOC appointment to the appropriate department (urology). So, there are no failings in the Trust’s actions at that time.
45. We now turn to the delays and administration errors Mr A faced while trying to make a TWOC appointment.
46. Our ‘Principles of Good Administration’ say public organisations ‘should behave helpfully, dealing with people promptly, within reasonable timescales’.
47. The medical notes show the SHO spoke to a member of the urology team at the Trust. The urology team said the specialist nurse (who carries out TWOCs) should pick up the TWOC request on their system and arrange the appointment.
48. Mr A’s notes show he had a GP appointment due to severe bladder pain on 10 September. This took place where he was staying temporarily. It is not clear whether this was before or after the phone call with the SHO. The SHO did fill out a form for a TWOC appointment on the same day.
49. On 12 September, Mr A went to A&E at the other NHS trust again as he was still in pain. The other trust advised him to get an appointment at the local urology clinic. Mr A tried to call this urology clinic but was unable to speak to anyone.
50. Mr A went to the Trust for his scheduled follow-up appointment for his foot surgery on 18 September. As there were concerns about his bladder and catheter problems, the Trust advised Mr A to go to A&E and ask for a urologist. Mr A did so. He did not see a urologist, but a clinician advised him the urology department would send an urgent referral to request an urgent TWOC appointment. The clinician said Mr A should return to A&E if his problems worsened.
51. Mr A called the Trust about the TWOC appointment on 23 September, but the Trust told him no appointment was scheduled, nor was he on any list for an appointment. The Trust advised Mr A this was because the clinician in A&E had sent the referral to the incorrect email address, but the Trust disputes this in its complaint response. The email was then sent to the correct email address. The Trust says there were delays due to the lack of response from the urology department.
52. As Mr A felt things were not progressing, he went to see a private urologist on 26 September and booked a TWOC procedure for 3 October. In the meantime, Mr A contacted the Trust several times to try and arrange a TWOC appointment. He left messages the Trust did not respond to, and no one was available to answer the phone on several occasions. Mr A’s private urologist carried out a successful TWOC procedure. It was only on 7 October when he received an email from the Trust advising him of a TWOC appointment for 11 October.
53. It took the Trust about a month from when it first requested the TWOC appointment to the scheduled appointment date. However, the Trust did not communicate with Mr A about his TWOC appointment until a few days before it was due to take place.
54. As explained previously, this is not the usual route for a TWOC referral as Mr A had not previously received any urological care from the Trust. So, we can understand there may have been some confusion as this referral did not necessarily come through the normal channels.
55. That said, the Trust, in its response, has accepted there were delays in the urology department responding to communications it had received on 10 and 23 September. We can see the Trust was trying to be helpful in arranging a TWOC appointment for Mr A following his discussion with the SHO on 10 September.
56. Overall, the delays on the part of the Trust are not in line with our ‘Principles of Good Administration’ as it did not deal with Mr A quickly. There are failings here in the Trust’s delays.
57. Mr A tells us he felt he had no choice but to seek private treatment, and he had a TWOC procedure on 3 October due to the extreme pain and discomfort he was experiencing. He tells us he also experienced inconvenience and financial expense for the private treatment.
58. We can see Mr A was proactive in trying to find out details about his TWOC appointment, but the Trust did not provide him with any meaningful update. As Mr A had no sign from the Trust when a TWOC procedure might take place, we can understand why he felt he had no choice but to seek a private TWOC appointment, particularly as he was still experiencing a lot of pain and discomfort.
59. Even after Mr A had booked a private appointment, he continued to make attempts to contact the Trust.
60. As explained earlier, the Trust has accepted there were delays on the part of the urology department. The Trust says it is putting plans in place to make the administrative team more responsive by providing training for its staff. It also says ongoing work is happening with administrative urology processes and the TWOC clinic. It says the urology department is looking to increase the number of appointments and locations for the TWOC clinic to increase capacity.
61. The Trust has accepted there have been errors on its part. It is encouraging to see it has already identified areas in which it could improve. However, we do not consider the Trust has provided an adequate apology to Mr A for the delays he faced and how this made him feel he had no choice but to seek private treatment. So, the Trust could do more to put things right.
62. We set out our recommendations to the Trust later in the report.
Arranging an appointment for outstanding issues
63. Mr A also faced further delays and administrative errors in trying to book an appointment with a consultant for his outstanding bladder and stomach issues.
64. The Trust says it received a GP referral for urology on 24 October 2019. It booked an appointment through its electronic system for 5 November. During the Trust’s vetting process, it misinterpreted this appointment as being for a TWOC procedure. It cancelled this appointment on 30 October as Mr A’s catheter had already been removed.
65. After the Trust cancelled this appointment, it placed the referral on a deferred list. It was triaged and booked for March 2020. Mr A cancelled this appointment as he would not be in the country.
66. Mr A tells us when he received the Trust’s email of 7 October about his TWOC appointment for 11 October, he contacted the Trust. Mr A told the Trust he did not need a TWOC procedure, but he still wanted to see a urologist to resolve his outstanding issues. The Trust told him he could ask his GP for a urology referral or he could attend the scheduled appointment on 11 October. At this appointment, Mr A asked the nurse if he could see a urologist and, if none were available, he asked the nurse to book a urology appointment.
67. At the appointment on 11 October, the nurse was not aware Mr A had already had a TWOC procedure. The nurse advised Mr A to ask his GP for a referral to urology.
68. The Trust has accepted it made errors about Mr A’s urology appointment. However, it does not seem to mention what happened from 7 to 11 October as outlined above. Overall, we think there is a failing here.
69. Mr A says he was in long-term extreme pain and discomfort. He says he has experienced inconvenience and financial expense.
70. After Mr A’s TWOC procedure, he was still experiencing general bladder issues and other problems. Based on the information we have, Mr A did not seek any further private treatment, so we do not think there was any further financial expense. The Trust did rebook Mr A’s appointment for March 2020, but this was some time after the original November 2019 appointment. It is unfortunate Mr A was unable to attend the March 2020 appointment as he was abroad. However, the Trust could not have anticipated this.
71. We understand the inconvenience of Mr A having to call the Trust to rearrange this appointment, especially as having to wait longer for an appointment, without any resolution to his outstanding health issues, must have been difficult for him.
72. We cannot be critical of the Trust for rebooking the appointment for March 2020. However, there was an error in cancelling the November 2019 appointment.
73. The Trust says it has appointed two locum (temporary) consultants to run general urology clinics to reduce waiting times and address capacity issues. The Trust says the cancellation of the 5 November appointment was due to human error. The Trust has apologised for the error and accepts Mr A’s patience and persistence in trying to rebook the appointment.
74. Our ‘Principles for Remedy’ say where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.
75. We think the Trust has done enough here to say what service improvements it has made to put things right. It has also apologised for the error (the cancelled November 2019 appointment). However, as mentioned previously, the Trust has not specifically addressed what happened between 7 and 11 October.
76. Considering the issues Mr A had already faced at this point, a cumulative (snowballing) inconvenience has built up here.
77. In terms of service improvements, we think the Trust has already broadly covered this in terms of the general administrative improvements it is working on. However, the Trust has not accepted what happened between 7 and 11 October.
78. We set out our recommendations to the Trust later in the report.
Complaint handling
Unanswered questions
79. Mr A complains the Trust refused to answer all his questions and told him he could take his complaint to us.
80. The Trust’s internal policy says the investigator is ‘under no obligation to investigate every single issue raised’. It goes on to say ‘investigators should discuss their proposed scope with the complainant and, where possible, obtain the complainant’s agreement’. It also says a final response to a complaint ‘will always refer the complainant to [us] so that [we] may consider an independent review’.
81. Our ‘Principles of Good Complaint Handling’ say public organisations ‘should provide clear, accurate and complete information to their customers about:
• the scope of complaints the organisation can consider • what customers can and cannot expect from the complaint handling arrangements, including timescales and likely remedies, and • how, when and where to take things further.’
82. After the Trust sent its second response on 6 May 2020, Mr A still had outstanding issues and questions for the Trust to answer. On 3 August, the Trust advised Mr A it could not respond any further to his complaint and the next step would be for him to take the matter to us.
83. Although the Trust has acted in line with its internal policy in deciding not to answer all Mr A’s questions, we cannot see the Trust informed Mr A of this policy. The Trust’s policy and our ‘Principles of Good Complaint Handling’ say public organisations should inform the complainant of the scope of the complaint and what they can or cannot expect from the complaints process.
84. From the evidence, we can see the Trust did not explain to Mr A it would not be able to answer every question he raised. Had the Trust followed its internal policy and our ‘Principles of Good Complaint Handling’, it may have helped manage Mr A’s expectations of what to expect during the complaints process.
85. Mr A also complains the Trust told him to take his complaint to us. The Trust’s actions here are in line with its internal policy and our ‘Principles of Good Complaint Handling’. The Trust, in its responses of 3 August and 18 September, correctly advised Mr A the next step would be to approach us.
86. We appreciate Mr A was keen to try to solve his complaint locally with the Trust. We are also sorry to hear Mr A felt he was being given the ‘run-around’ and was being ‘fobbed off’.
87. There are failings in the Trust not answering all Mr A’s questions as the Trust did not advise him it did not have to or could not do this. There are no failings in the Trust advising Mr A to take his complaint to us.
88. Mr A says the Trust was ‘ignorant’ and ‘blasé’ in not answering all his questions. While we are not necessarily critical of the Trust not answering all the questions raised (in line with its internal policy), it did not advise Mr A of this. Had the Trust made Mr A aware of what he could expect from the complaints process and what it was going to investigate or not, Mr A may have better understood the Trust’s reasoning and not thought it was dismissing his concerns.
89. We set out our recommendations to the Trust later in the report.
Legal action
90. Mr A complains the Trust encouraged him to take legal action which he says was inappropriate. Mr A did not want to sue the Trust as he says this is not in his nature.
91. The Trust’s internal policy says ‘complainants who express a wish to take legal action or to obtain compensation should be advised how to seek independent legal advice’.
92. Mr A emailed the Trust on 13 March 2020 in response to its letter of 5 March. In his email, he says the Trust ‘should be held financially accountable’ for the mistakes it made.
93. The Trust’s complaint response of 6 May accepts Mr A’s opinion on financial implications, but says this is not something it ‘can comment on or take forward’. As such, it suggests Mr A may wish to ask for legal advice, and it provides details of different organisations through which Mr A could find a solicitor.
94. The Trust’s response here is in line with its internal policy. Mr A told the Trust how he thinks its mistakes make it ‘financially accountable’ and how he had to pay for a private TWOC appointment. So, the Trust advised him on how to seek independent legal advice.
95. There are no failings here.
Inaccurate response
96. Mr A says it was inaccurate for the Trust to say it was at an ‘impasse’ with his complaint.
97. The Cambridge Dictionary defines ‘impasse’ as ‘a situation in which progress is impossible, especially because the people involved cannot agree’.
98. Our ‘Principles of Good Complaint Handling’ say public organisations should ‘provide clear and accurate information about the next stage of the complaint process so the complainant is clear about what to do next if they remain dissatisfied’. Public organisations should also avoid any unnecessary delays.
99. Mr A sent three replies to the Trust’s 6 May 2020 response. He was still asking for clarification of parts of his complaint and he had unanswered questions. Mr A was also asking for a meeting with the Trust to discuss his complaint.
100. The Trust sent Mr A an email on 3 August after reviewing his communications. It said a senior clinician and the head of its complaints department had reviewed its complaint responses. The Trust’s complaints manager felt it had reached an impasse in the complaints process as it would not be able to respond any further.
101. We think the latter part of the definition of ‘impasse’ is relevant here. Mr A was not satisfied, nor did he agree with the Trust’s explanation for the main part of his complaint – the TWOC procedure when he was in hospital on 6 to 7 September. Mr A outlined what he thought would resolve this matter (an apology and service improvements) and suggested how to deal with several other recommendations he had made.
102. We can see the Trust and Mr A had different ideas on the next stage of this complaint, especially as the Trust did not think it could add any further comments or explanations to what it had already said.
103. We appreciate Mr A strongly disagrees his complaint had reached an impasse. He did not think this was the case as he explained how he thought the Trust could easily resolve his complaint. The Trust held a different view. As the Trust had concluded it carried out the TWOC procedure correctly and had explained its position on other matters, we cannot see what more would have been gained by repeating these explanations.
104. As mentioned earlier in the report, the Trust appropriately referred Mr A to us as he remained dissatisfied with the Trust’s response. Simply repeating its position on Mr A’s complaint (which it had already done) would have caused an unnecessary delay in Mr A taking any further action. Again, while we know Mr A wanted to resolve his concerns locally, there came a point when the Trust could not do more than it had already done.
105. In this case, we consider the use of the word ‘impasse’ correct. However, this does not mean Mr A’s interpretation of the term is incorrect as interpretation is subjective. Overall, we find no failings in the way the Trust communicated with Mr A on this occasion.