Postponed surgery
14. Mrs R says the delay in surgery meant open surgery was done instead of the planned keyhole surgery. She says she now has a large scar which she feels could have been avoided. Mrs R had digestive issues for two months after surgery and more recently has had treatment for a dangerously low white blood cell count. She questions whether these things could be linked with her delayed surgery.
15. Mrs R says after her discharge from hospital, solid food was impossible for her to eat as it caused severe diarrhoea. She says she had severe, intermittent abdominal pains for around two months after surgery.
16. Mrs R says the issue with her low white blood cell count happened in early September 2021, six months after the open appendicectomy surgery. She says she was advised this issue could have happened because her immune system was compromised by getting gangrene and the subsequent infection while in hospital, but this could not be confirmed. She says she did not have any other medical factors that could have caused this.
17. The Trust’s complaint response says Mrs R’s surgery was postponed because the emergency operating list on 13 April was very busy with patients whose surgery was a higher priority in terms of risk to life or limb. It says the emergency surgery operating list priority procedure was followed throughout. It apologised it was unable to do the operation sooner and referred to the CEPOD classification guideline.
18. The medical records show a consent form signed by Mrs R on 12 April 2021 (the same date she was admitted to hospital). The consent form details the risks involved and one of them is ‘conversion to open surgery’.
19. Our adviser says there are no guidelines for prioritising emergency surgery patients other than general CEPOD advice. This study explains that timing of the appendicectomy will depend on how sick the patient is, what other emergency operations need doing and the skill mix and number of staff available to run theatres. Our adviser says the decision is a clinical one and should be guided by GMC’s ‘Good medical practice’ guidelines:
‘15 you must provide a good standard of care. If you assess, diagnose or treat patients, you must:
a. 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 b. promptly provide or arrange suitable advice, investigations or treatment where necessary…
18 you must make good use of the resources available to you.’
20. Our adviser says it would be appropriate to prioritise patients who need more urgent emergency surgery above Mrs R. Also, it is not unusual for this to happen to patients needing appendicectomy due to pressures on operating theatres.
21. We asked our adviser if the delay in surgery would have increased the risk of changing to open surgery. Our adviser says it is difficult to be sure but, in general, operating sooner is likely to give a better chance of completing keyhole surgery.
22. Our adviser says the clinical notes about the scan done on 12 April highlight that an abscess or perforation had already been identified and this is the likely cause for the open surgery, rather than the delay.
23. Our adviser says after an open appendicectomy procedure it may take four to six weeks to recover, and the digestive issues and scarring are expected.
24. We explored if a two-day delay and an open appendicectomy could lead to the low white blood cell issues and found no supporting guidelines or case studies. Our adviser says they are not aware of any reason why complications from appendicectomy could cause this.
25. There is no clear evidence that the delays caused the operation to be switched from keyhole to open surgery.
26. We recognise the wait for surgery was very traumatic for Mrs R and the family. Our view is the delay was not due to any failings by the Trust as there was a high demand for emergency treatment during this time. The Trust’s actions were in line with relevant guidelines. For this reason, we will take no action on this part of the complaint.
Discharge report
27. Mrs R says failing to document the repeated delays in the discharge report suggests her condition was not seen as a priority despite being admitted as an emergency patient.
28. In its response, the Trust says the Emergency Surgery Operating Priority List Procedure was followed throughout.
29. Having looked at the discharge report, it only shows details of the clinical procedures and does not mention surgery postponements.
30. BMJ guidelines say the discharge summary must include:
• under which team, and preferably which named consultant, the patient was admitted • the reason the patient was admitted • the diagnosis • investigations and the results • the treatment given • any changes to medication and reasons why • what the patient has been told • any follow up arranged from hospital.
31. There is a set template for this document which was followed by the hospital in this case and all of the relevant information was included. There is no requirement to include details of surgery postponements and they should be limited to the key clinical information.
32. Our adviser says it would not be normal practice to include details of surgery postponements in a patient’s discharge summary.
33. While we acknowledge Mrs R’s frustration, the Trust acted in line with guidance when completing the hospital discharge summary. There is no sign of maladministration (fault) and for this reason we will be taking no further action on this part of the complaint.
The Trust’s complaint response
34. Mrs R is unhappy with the Trust’s response and feels it gives no real explanation for the delays and why other patients were prioritised. She feels it gives an insincere and bland apology.
35. Mrs R expressed she would be satisfied if the Trust sent a further apology and letter of explanation for the reasons why her surgery was delayed. We contacted the Trust to discuss the opportunity to resolve this part of the complaint.
36. The Trust agreed to provide a letter of apology and explanation of other patient circumstances which caused them to be prioritised over Mrs R.
37. We appreciate the level of anxiety caused by Mrs R having not been given clear and detailed explanations for the delays. This resolution will put right the impact caused by the Trust. It is in line with our ‘putting things right’ principle of our ‘Principles of Good Complaint Handling’, and gives Mrs R an appropriate and fair solution.
38. We recognise Mrs and Mr R experienced distress and we are sorry to hear of this. We hope they are reassured by our investigation and understand the reasons why we are taking no further action.