Somerset NHS Foundation Trust

3. Mr A complains that the Trust caused irreparable damage and incontinence by irresponsibly and aggressively inserting a catheter (a thin tube inserted into the bladder to drain urine) in May 2021.

4. Mr A says that due to the violent way the catheter was inserted and due to the size of the catheter chosen, he experienced internal damage and bleeding. He says that since then he has been unable to control his bladder. He is now incontinent and this prevents him from leaving his home, visiting his family and having independence. He says this is taking a big emotional toll on him and it is greatly affecting his mental health.

5. Mrs A also explains that the events have had an impact on her as the carer and it is distressing for her to have to see him so severely affected. She says her mental health is also suffering because she has to see her husband struggle so much.

6. They want a financial payment for the impact and apologies and acknowledgements from the Trust.

7. Mr A complains that after an endovascular aneurysm repair (a type of surgery) in May 2021, the Trust caused irreparable damage to his urethra by reinserting a catheter.

8. Mr A says that while in recovery from the procedure, nursing staff attempted to reinsert a catheter but could not do it. He says the consultant urologist was called to fit it. He says the urologist used a bigger catheter and inserted it using an adapter. He says this was shoved in without care and caused him to scream out in pain.

9. He says after this he experienced bleeding from his penis for several days and now has total urinary incontinence. He says he had some stress leaks (leaking urine when under pressure) before this, due to surgery on his prostate. But, this could be managed with pelvic floor exercises. Mr A says now he has no control of his bladder. This causes him to have to wear pads and he does not like to leave the house because he fears having leaks in public.

10. Mr and Mrs A say the impact of this damage is physical and mental. They explain that because Mrs A is a full-time carer for Mr A, she also stays home with him. She also helps with continence and cleaning. They can no longer travel or go out and see people and in particular, struggle emotionally with being unable to see their daughter because she lives far away and they are now unable to travel to her.

11. We understand how difficult a time Mr and Mrs A are having and that Mr A is due to have a second opinion soon on his condition. We hope that some support for incontinence can be provided, and this will help them to enjoy more time outside the home and to see their daughter.

14. The law says a complaint needs to be made to us within one year from when someone knew they had a reason to complain.

15. We think that after the event on 23 May 2021, it may have taken some time for Mr A to realise the extent of the damage caused when inserting the catheter. At the latest, we think this may have taken a month, so we think the latest date for when Mr A would have known he had reason to complain would be 30 June.

16. This means we would expect the complaint to be made to us by 30 June 2022. We did not get the complaint until 20 November 2023. This means the complaint was made to us one year and five months out of time.

17. We do have some discretion to put the time limit to one side if there are strong reasons to. We look at the reasons for delay and the time it took for the organisation to handle the complaint.

18. We can see that Mrs A was actively pursuing the complaint over a number of months. She made four complaints in total and two subject access requests (SAR) to the Trust.

19. We can see that the Trust contributed to some of the delays in Mrs A bringing her complaint to us. Some of these were due to Mrs A making the SARs. These are not part of complaints process and Mrs A could have approached us when she was unhappy with the Trust’s complaints responses.

20. We appreciate Mrs A may have felt there was more evidence available that she wanted to see. But, she also could have brought her complaint to us after making the first SAR.

21. Some of the delays caused by the SARs were not necessary to complete the complaints process. This means we do not see these delays as being a good reason to put our time limit to one side.

22. We can see there were also some significant delays in the complaints process. In total there were 68 weeks of delays. This makes up over a year of delays in total. This is a long time and we think it could have been largely avoided.

23. We asked Mr and Mrs A why there had been delays in progressing the complaint and bringing it to us.

24. Mrs A explained she was passed between departments when raising her complaint which wasted her time. She also explained that she is in her eighties with her own health problems. She also suffers stress due to caring for Mr A and seeing his distress is causing her anxiety. She says she has been exhausted from caring for Mr A and her own health conditions and this has caused the delays.

25. We can entirely understand that the complex care needs of Mr A and Mrs A’s own health would have contributed to delays. We appreciate some delay would have been unavoidable. But, the SARs were not necessary and delayed the complaint being brought to us by 23 weeks.

26. The rest of the delay can be accounted for, in part, by Mr and Mrs A’s health conditions. But, it was a large delay of over a year. During this time we think the complaint could have come to us. We have not seen strong enough reasons to put the time limit to one side.

27. We appreciate this will be upsetting news and we recognise they have tried many routes to resolve this issue because it is very important to them. We are sorry for any upset our decision may cause and wish Mr and Mrs A all the best with their future health.

1. We have carefully considered Mr A’s complaint about Somerset NHS Foundation Trust (the Trust). Unfortunately, the complaint falls outside of our time limit and we have not seen good reason to put the time limit to one side.

2. We understand that Mr A experiences incontinence that seriously affects his freedom to enjoy his life. We empathise with what Mr A and Mrs A are going through and are very sorry to hear how what happened affects their ability to enjoy activities.