Refusal to do gastric surgery
15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.
16. The Trust saw Miss H on 19 May 2021 and in its letter typed on 12 July 2021, it confirmed it gave Miss H information about the medical pathway(‘tier three’) weight loss programme and she was aware of what was expected.
17. The letter also confirmed Miss H was attending the programme ‘with a view to consideration of bariatric surgery in the future…and an onward referral to the surgical pathway (‘tier four’) for consideration for bariatric surgery can be made on completion of tier three’.
18. A Trust letter dated 16 August 2021, again confirmed that while bariatric surgery is a goal, it would need to carefully evaluate aspects of Miss H’s mental health before surgery can go ahead.
19. On 29 September 2021, a Trust psychologist completed a clinical psychology assessment with Miss H. During this assessment, Miss H confirmed she had recently self-harmed. The Trust letter detailing this assessment confirms this discussion.
20. Miss H said that this was a single episode of self-harm. She does not disagree that the self-harm took place.
21. The Trust letter reconfirmed Miss H needed to be free from self-harm and binge eating for at least 12 months before surgical options can be considered.
22. Miss H spoke to the Trust in December 2021. She was concerned about the psychology assessment in September 2021. During the conversation, the Trust reminded Miss H that she must be 12 months free from self-harm to be considered for surgery.
23. There is further evidence in a Trust email dated 20 April 2022, that notes Miss H reported a self-harm incident at her appointment on 12 January 2022, although we do not know if this was the same incident or a different one.
24. The Trust weight management policy for tier three says:
‘When you have successfully completed the tier three programme, you will either be referred back to your GP or local healthcare provider for continued support or can be considered for referral to tier four if you wish to pursue assessment for bariatric surgery and meet the criteria at that time’.
25. The Trust confirmed it would have completed further assessments on Miss H’s mental health if she had progressed to tier four. It also said bariatric surgery cannot be confirmed until the Trust are happy the patient is physically and mentally suitable.
26. The Trust response dated 8 September 2022 says the consultant explained the requirement of 12 months stability in mental health to Miss H and that a follow up appointment for continued support had been arranged for her. The letter also confirmed that the day before the scheduled follow up appointment, the consultant received an email that advised Miss H had already been abroad for surgery.
27. The Trust response confirmed Miss H was following tier three and did not have funding for tier four at the time.
28. On 2 March 2022, the Trust sent Miss H a follow up appointment letter, advising her appointment had been rearranged from 9 March to 21 April 2022.
29. Miss H’s medical records show the Trust was not aware of her travelling abroad for surgery until the day before the prearranged follow up appointment on 21 April 2022. The Trust was still progressing Miss H through the tier three pathway.
30. The day before this consultation, the Trust confirmed to the dietician overseeing Miss H’s care that she had already travelled abroad for bariatric surgery. During Miss H’s phone conversation with the dietitian, on 21 April 2022, the Trust confirmed Miss H did not have funding for tier four.
31. The Trust response dated 8 September 2022 said Miss H discussed post operative symptoms with the dietician during her phone consultation on 21 April 2022.
32. The Trust did not decide to withdraw surgery from Miss H, as it had not completed a clinical assessment for surgery. The Trust says this assessment would have been completed at the beginning of tier four.
33. Having started on tier 3 in May 2021, Miss H was still on tier 3 in September 2021, when she met with the Trust psychologist.
34. It is possible there was a communication issue in relation to the letter Miss H received from the Trust in October 2021, which may have led her to believe she was not able to be considered for surgery at all.
35. The letter says: ‘I would suggest conservative treatment of your weight difficulties now, rather than steps such as bariatric surgery as surgical options can worsen mental health problems. If you reach a point where you have been free of self-harm and binge eating for at least 12 months, at this point surgical options can be considered’.
36. We cannot confirm if the Trust would have allowed Miss H to have surgery at this time, as the 12-month review of the tier three programme was never reached, before Miss H decided to have surgery abroad. We conclude the Trust followed the policy correctly during the time Miss H was following tier three.
37. Miss H’s clinical notes confirm the Trust had booked a further tier three follow up review for her. This phone appointment took place on 23 June 2022, with an obesity nurse. During this consultation Miss H confirmed she had surgery abroad and said she did not want any support from the Trust. She was unhappy with the service she had before.
38. We have seen no evidence to support Miss H’s view that the Trust were wrong to refuse surgery at this time as it was not a part of the tier three medical pathway she was following.
39. While we appreciate Miss H made a difficult decision when she chose to travel abroad for her surgery before her 12-month review, we have seen nothing to indicate the Trust did anything wrong.
No contact with mental health team or GP
40. Miss H saw a psychologist in September 2021 as part of her tier three assessment. The Trust letter dated 1 October 2021 details the discussion of Miss H’s mental health. This is in line with BOMSS guidance to take a detailed history from the patient, including any mental health issues.
41. The clinical review completed by the Trust at Miss H’s assessment on 29 September 2021 was completed in line with BOMSS guidance, which says a detailed dietary history should be taken and patients should be assessed for psychological and lifestyle issues including anxiety and depression, self-harm and suicidal behaviours as well as eating disorders such as binge eating, to be able to identify if a patient may need additional support or be at risk of self-harm after surgery.
42. The written assessment dated 1 October shows the Trust discussed this with Miss H at her appointment, and suggested self-help resources after Miss H confirmed she did not wish to access any psychological therapy at the time.
43. The Trust also requested Miss H’s mental health records from her GP on 12 July 2021 and again on 16 August 2021. The Trust received these documents. The Trust’s bariatric team were aware of Miss H’s mental health issues.
Communication from dietician
44. In a Trust letter dated 18 May 2022, the dietician says: ‘Unsurprisingly she is already having issues related to her surgery that she went abroad’.
45. The letter confirms she went abroad for bariatric surgery, against Trust advice about the stability of her mental health, before the Trust would complete the procedure.
46. The letter summarises a phone consultation with Miss H on 21 April 2022, stating she was having issues with the surgery. It further confirms the Trust had no funding to support Miss H after her operation. The Trust discharged her back to the care of her GP.
47. Miss H received a copy of this letter that was sent to her GP.
48. GMC ‘Good medical practice’ says that all communication with patients and colleagues should be honest and trustworthy, making sure that all information given is accurate.
49. The Trust’s letter to Miss H’s GP confirmed the facts of Miss H’s operation abroad and provided what appears to be accurate information about the conversations the Trust had with her relating to her mental health.
50. During a phone conversation with the Trust dietician on 21 April, Miss H explained she was vomiting and unable to keep food down. Miss H confirmed she had not discussed this with her private consultant. The Trust noted this in its response dated 8 September 2022. The Trust identified these complications in its letter to Miss H’s GP dated 18 May 2022.
51. The NICE Quality Standard says: ‘people who have had bariatric surgery have a follow-up care package within the bariatric surgery service for a minimum of two years’. This should include regular health check-ups, nutrient testing dietary support and psychological support if needed.
52. NHS UK Risks-weight loss surgery (2020) explains the risks involved in weight loss surgery including blood clots, wound infection, and leaks or blocks in the gut. A symptom of a blocked gut is vomiting.
53. The letter dated 18 May 2022 contains the dietician’s opinion that she was not surprised that Miss H was having issues relating to her surgery as complications are not uncommon after gastric surgery.
54. The UK National Bariatric Surgery Registry Report 2020 says the most common complications of primary bariatric sleeve surgery are bleeding (13%), and a leak in the gut (7.4%).
55. While we can understand that Miss H may feel the comments were ‘rude and unprofessional’, we believe the concerns of the dietician about post-surgical complications were reasonable, due to the complications that can arise from this kind of surgery.
56. GMC ‘Good medical practice’ also says that doctors should be polite and considerate and respect the dignity of patients. It also says patient choices should be respected.
57. It is possible Miss H felt the dietician was not being respectful about her decision to go abroad for surgery. We conclude that the comments were more in line with the potential side effects from surgery, rather than the implication that she travelled abroad for surgery.
58. We appreciate the letter may have caused Miss H distress as she was recovering from her operation, but we can see no evidence the Trust did anything wrong.