NHS in England Closed After Initial Enquiries Search on PHSO website

Sheffield Teaching Hospitals NHS Foundation Trust

P-002445 · Statement · Decision date: 27 February 2024 · View Sheffield Teaching Hospitals NHS Foundation Trust scorecard
Treatment Communication Nursing care Clinical negligence harms learning
Complaint (AI summary)
Miss O complained the Trust caused a diaphragm tear during surgery, leading to a collapsed lung, poor communication, and inadequate nursing care, causing nerve damage and life impacts.
Outcome (AI summary)
Complaint closed. The ombudsman advised Miss O to seek legal advice to resolve her concerns.

Full decision details

The Complaint

3. Miss O complains about the Trust’s care and treatment in November and December 2022. She says the Trust:

• caused a small tear in her left diaphragm during an operation resulting in a collapsed lung • communicated the tear in the diaphragm poorly • gave poor nursing care.

4. Miss O says she had to have a second operation, which she was very afraid of and she has nerve damage on her left side. She says the nerve damage is so bad she cannot wear a bra which she is embarrassed about. She has limited use of her left arm, is not able to hug her children or grandchildren and has weakness and breathlessness.

5. Miss O also says she lost her job and her partner, Mr H, had to become her carer. She and her family have experienced distress, she has panic attacks and nightmares and her mental health has got worse affecting her quality of life. Mr H explained Miss O is not the same lady and the experience has ruined their life.

6. Miss O wants a financial payment, changes to service and an apology from the Trust.

Background

7. At the end of November 2022 Miss O went to the Trust for day surgery. She had laparoscopic fundoplication, which is a small surgical procedure, to treat her severe reflux and hiatus hernia repair (when your stomach moves up into your chest).

8. Because of the COVID-19 pandemic, she had waited over two years for her operation, she had lost weight and her hair was falling out. The acid reflux affected Miss O so much she was not able to eat, she was being sick and she was very weak.

9. During the operation the clinician caused a small tear in her left diaphragm resulting in a collapsed lung. The clinician stopped the operation and the Trust admitted her into critical care. The clinician did not explain clearly to Miss O why this happened and told her air was escaping.

10. After two days on the ward, staff had not moved Miss O to make her more comfortable and her catheter bag (used to empty the bladder when it is not working naturally) was full. Staff did not change the catheter bag until her family complained.

11. Four days passed and staff had not checked the chest drain dressing and wound that was causing an infection and spreading to her left breast. Only after Miss O’s family complained did staff check her wound and antibiotics were given.

12. The next day the surgeon saw Miss O and told her she had water on her lungs and there were signs of infection. The Trust needed to drain her lungs.

13. Miss O says the Trust left her without appropriate pain and hormone medication. She also complains about the nursing care. She says nurses left her to urinate halfway between the toilet door and the corridor in full view of everyone, with her pyjamas halfway down her legs and showing her naked lower half which was very embarrassing.

14. She also says nurses on the ward woke her and washed her without dignity, by spreading her legs open and they ‘scrubbed’ her vagina.

15. Miss O especially remembers a nurse who did not know about her care, giving poor care when giving her cannular medication and they had a poor bedside manner. She says they did not give pain relief or water, did not respond to her buzzer and spoke about her rudely.

Findings

17. The Health Service Commissioners Act 1993 (the law) says we cannot investigate a complaint if there is (or was) a legal route that can be taken unless it is (or was) not reasonable to do this.

18. Miss O says the Trust stopped the operation quickly but, it did not say why and it only told her air was escaping. Miss O says the day surgery turned into being admitted for a week. During this time Miss O says she did not get the correct nursing care and her wound became infected which spread to her left breast.

19. Miss O wants a financial payment, changes to service and an acknowledgement and an apology from the Trust.

20. Miss O said she did not know how much financial payment she wanted because this was not the main thing she wants.

21. Since making her complaint, Miss O has become more unwell, Mr H has had to become her carer and she is now being checked for postural tachycardia syndrome (when your heart rate increases very quickly after getting up from sitting or lying down).

22. We explained to Miss O how we must check if someone has a legal route available to them and how we give financial payments differently to a court (as a result of successful legal action). Miss O says she would find the legal process very stressful and reliving the experience affects her anxiety. Miss O also says her mind has been affected by the operation and she struggles with simple tasks.

23. Miss O says financial payment would be good, but it is not all she wants..

24. We thought carefully about what Miss O told us. How she says she was affected by what happened is serious. A legal route may be a better option for her and her family because of this.

25. We are not able to recommend as much money as a court can and we cannot recommend money for any ongoing impact like a court can. We think legal action would be better to achieve what she wants and is suitable for her case.

26. We asked Miss O if she had thought about a clinical negligence claim and any reasons why she would not be able to do this. Miss O did not say she and her family could not make a clinical negligence claim. Changes to service, an acknowledgement and apology can be achieved by legal action.

Our Decision

1. We have carefully considered Miss O’s complaint about Sheffield Teaching Hospitals NHS Foundation Trust (the Trust).

2. We will not take any further action on Miss O’s complaint because she can take legal advice to resolve her concerns. We are sorry to hear about Miss O’s and her family’s experience.

Other Decisions About Sheffield Teaching Hospitals NHS Foundation Trust

P-005114 · 26 Mar 2026
Mr I complains the Trust failed to review his medication when he raised concerns that one of the medication had …
Closed After Initial Enquiries
P-005120 · 26 Mar 2026
Mrs B complains about aspects of the care provided to her late mother, including a lack of assessments and investigations …
Partly Upheld
P-004868 · 20 Feb 2026
Dr D complains about the service she received from the Trust. She complains the Trust discussed Dr D previous complaint …
Not Upheld
P-004678 · 26 Jan 2026
Mrs G complains about a failure to record and act upon symptoms which she says could have reasonably led to …
Not Upheld
P-004517 · 18 Dec 2025
Mrs H is concerned about the Trust’s transparency surrounding events concerning her daughter’s death in October 2023.
Closed After Initial Enquiries
View all decisions for this organisation →