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South Tyneside and Sunderland NHS Foundation Trust

P-002616 · Statement · Decision date: 15 May 2024 · View South Tyneside and Sunderland NHS Foundation Trust scorecard
Complaint (AI summary)
Mr A complained the Trust improperly extended his chemotherapy cream use beyond recommended limits and provided no warnings, resulting in a permanent facial disfigurement.
Outcome (AI summary)
The ombudsman decided not to investigate further, advising that legal action is a suitable course of action for Mr A to pursue.

Full decision details

The Complaint

3. Mr A complains between October 2022 and January 2023 the South Tyneside and Sunderland NHS Foundation Trust (the Trust):

• left him to use Efudix cream (a chemotherapy cream) for over three months when it should not be used for more than four weeks • gave him no specific instructions of warnings about using Edufix cream.

4. Mr A says this has left him with a permanent crater on his nose, which has made him self-conscious about his appearance. He says the extent and permanence of this facial disfigurement was not confirmed for months which was distressing for him.

5. Mr A wants personal apologies from the Trust for what he describes as medical negligence. He also wants financial compensation for the noticeable scar and permanent disfigurement.

Background

6. In June 2022, Mr A visited his GP as he had a small pinhead sized blemish on his nose. The GP prescribed a week-long course of medicated cream called Aldara for actinic keratosis (areas of sun damaged skin on head or body). Aldara cream can also be used to treat a form superficial skin cancer called a basal cell carcinoma. The GP took photographs of the blemish on Mr A’s nose as precaution and sent them along with a referral to the dermatology team at the Trust.

7. On 31 October 2022, Mr A had an appointment with a dermatology consultant at the Trust, who examined Mr A and diagnosed basal cell carcinoma (a type of skin cancer that most often develops on areas of skin exposed to the sun). The Trust prescribed Efudix cream, which can be used to treat actinic keratoses and basal cell carcinoma).

8. On 20 November 2023, Mr A had an appointment with a different consultant at the Trust who advised him after examining him he would not need a biopsy. The consultant confirmed Mr A’s scarring was soft tissue damage due to the prolonged use of the Efudix cream.

Findings

11. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mr A to understand the circumstances and the outcomes he wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

12. Mr A complains about the Trust prescribing Efudix cream when he had a small pinhead sized blemish on his nose. He was using the cream between October 2022 and January 2023. He says the only instruction he was given was to use it sparingly, he was not told how long he should use it for.

13. Mr A says he raised concerns with the Trust pharmacy on 8 January 2023. After viewing his medical records, the pharmacy told him to continue to use the cream. On 15 January 2023 he had an appointment with his GP to raise his concerns about the use of the cream, he was concerned a small pinhead blemish which was there originally, had now turned into a larger scab on his nose. We can understand why this was concerning to Mr A.

14. The GP told Mr A to stop using the cream immediately and to contact the dermatology department to see the consultant again. Mr A told us roughly three weeks later the scab came off, leaving him with what he describes as a ‘crater’ on his nose.

15. Between 17 April and 4 September 2023, Mr A had three face to face appointments and one telephone consultation with consultants at the Trust where they discussed completing a biopsy procedure to find the cause. Mr A told us he was reserved about this due to the information he received about how the procedure was completed, as he was advised about the possible aftereffects of skin graphs from his neck to cover the area of the biopsy.

16. On 20 November 2023, Mr A attended an appointment with a new dermatology consultant, who examined his nose under magnification and said a biopsy would now not be necessary. Mr A says the consultant confirmed that the scarring on his nose was due to tissue damage, caused by prolonged use of Efudix cream.

17. Mr A says he is now in a situation of looking considerably worse than the original two millimetre diameter pink smooth blemish he had originally to what now resembles a ten to 12 millimetre crater on the tip of his nose. He says this is irreversible damage to his skin.

18. He told us he feels dismissed by medical staff as this being a side effect of using the cream. He says he is now scarred on what he considers possibly the most noticeable part of his anatomy leaving him with permanent disfigurement. We appreciate why this is so concerning and distressing to Mr A.

19. Mr A is seeking a financial remedy as one of the outcomes of his complaint for the damage the prolonged use the cream has caused. We can achieve financial remedies for complaints where we identify a failing which has caused an injustice. This means we may be able to achieve Mr A’s outcome. He told us he believes the permanent disfigurement is due to clinical negligence by the Trust and the dermatology consultant.

20. The law says a complainant must pursue a legal remedy if one is available before we consider the complaint further.

21. We consider there may be a cause of action available to Mr A to make a clinical negligence claim against the Trust.

22. Mr A is seeking a financial remedy for the permanent disfigurement to his nose from the prolonged use of the Efudix cream over a three-month period. We asked Mr A if he had thought about what amount of financial remedy he wants. He told us he could not put a figure on it as this is scarring he will have for the rest of his life. He told us he would discuss this with a solicitor.

23. Mr A told us he did not expect to go to see medical professionals and receive treatment which resulted in permanent disfigurement from using a prescribed cream the Trust gave him.

24. Mr A told us he had not considered legal action before he came to us. We discussed funding a legal claim and Mr A was not concerned about the cost of pursuing legal action as he felt very strongly about his outcome. We have noted often these types of legal claims can be funded by way of no win no fee agreements. There are also other funding options Mr A may be able to consider.

25. Mr A can discuss the funding options available with a solicitor. Mr A advised us he would seek legal advice from a clinical negligence solicitor to see whether he is able to make a legal claim against the Trust. There do not currently appear to be any barriers to the funding of such a claim.

26. In our discussion, Mr A agreed to seek advice from a solicitor which suggests there were no other barriers to pursuing legal action. Mr A has not informed us of any physical or mental health issues that would make this action difficult for him.

27. Mr A could not give an amount of financial remedy he wanted however, he wants compensation for the permanent disfigurement he has sustained. Our conversation with him, he wants a figure that is worthwhile him pursuing.

28. While we can make recommendations for financial remedies, we do not achieve financial outcomes in the same way the courts do, and it would seem legal action would be the best route for Mr A to achieve his main desired outcome.

29. We considered Mr A’s other outcomes. He wants the Trust and in particular the consultant to apologise for what he describes as medical negligence in prescribing the cream and not instructing him about the correct use or the length of time he should use it for.

30. The courts cannot direct the Trust or the consultant to apologise however, such apologies may come as a by-product of successful legal action. If Mr A has outstanding outcomes following legal action, he can return to us. He should be mindful of our time limit if he would like us to reconsider his complaint.

31. As we consider it is reasonable for Mr A to pursue legal action, we cannot consider the case further. We have notified Mr A we will be closing his complaint.

32. We do not wish to underestimate the emotional impact this had on Mr A. We are sorry to read his physical appearance is affecting him daily.

33. We thank Mr A for bringing his concern to us.

Our Decision

1. We have carefully considered Mr A’s complaint about South Tyneside and Sunderland NHS Foundation Trust (the Trust). We consider Mr A could take legal action and seen no evidence to suggest it is not reasonable for this to be pursued.

2. We are sorry to hear about what happened to Mr A and the daily impact this has had on him.

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