East Kent Hospitals University NHS Foundation Trust

4. Ms S complains that from September 2019 the Trust failed to diagnose her hernia and it took until May 2022 when she had surgery in Belgium to fix the hernia. She says she suffered pain for years, it was traumatic and caused her distress and anxiety. Ms S would like an apology from the Trust, service improvements and financial compensation.

5. Ms S had gastric bypass surgery in Belgium in 2016. She was experiencing severe abdominal cramps in 2019 and was diagnosed with irritable bowel syndrome (IBS) which she was told was stress related and she was given anti-depressants. An out of hours GP visited Ms S at home on 5 September as she had been in pain for three weeks.

6. Ms S attended the Emergency Department (the ED) at the Trust twice on 6 September with abdomen pain. The Trusts carried out an X-ray of her abdomen and chest and discharged her. Ms S had a CT scan on her abdomen and pelvis with contrast the next day at the Trust.

7. On 23 September Ms S attended the ED by ambulance with abdominal pain. She was discharged. She attended an appointment with a gastroenterologist on 14 March 2020. She attended the ED again on 18, 19 and 20 September 2021 with abdominal pain while she was pregnant. She saw a bariatric consultant at another Trust on 22 November.

8. Ms S had her baby on 8 January 2022. She travelled to Belgium on 13 June where she visited a private gastroenterologist. They diagnosed a Petersen hernia (Petersen hernia is a rare internal hernia occurring after any type of stomach bypass surgery). and operated to treat this.

11. Ms S says that despite visiting the Trust several times between September 2019 and November 2021 and having tests, it did not diagnose that the cause of her abdominal pain was a Petersen hernia. She says she suffered pain for years, it was traumatic and caused her distress and anxiety. She says she had to go and pay for private surgery in Belgium to fix the hernia. She says she was diagnosed with IBS and they suggested that it was her diet and stress related, due to her being a teacher, and just gave her anti-depressants.

12. Ms S had a CT scan on her abdomen and pelvis with contrast at the Trust in September 2019. The report of the scan says, ‘we are wary of internal hernia that is usually common on post bariatric surgery, we would like to rule this out – an internal hernia cannot be definitely excluded’.

13. Our general surgeon adviser explained that NIH guidance says internal hernias after bypass surgery can be difficult to diagnose with 15% showing no radiological abnormality. They explained the bowel is mobile and a hernia can be missed.

14. That said, our radiologist adviser went on to explain that the CT scan was not correctly reported. They said it showed appearances consistent with small bowel malrotation, which is a bowel twist that effects the blood supply, and is commonly seen in an internal hernia, such as a Petersen hernia. Therefore, the Trust has failed to diagnose an internal hernia.

15. Our radiologist adviser says the radiologist should have reported the appearances as highly suggestive of an internal hernia and should have recommended a review by a bariatric surgeon. They said they did not think the radiologist’s comment in the issued report that ‘an internal hernia cannot be definitely excluded’ is sufficiently specific or accurate.

16. To add to this the discharge summary the Trust sent to her GP said, ‘this lady has undergone CT investigation that has shown no internal hernia or acute pathology’. It did make a recommendation she see a bariatric surgeon but with no indication explaining why.

17. Our GP adviser said based on the discharge summary the Practice would have concluded that Ms S did not have a hernia. The Practice was not sent the actual CT scan report.

18. Our general surgeon adviser explained this meant there was a delay in obtaining an expert opinion from a bariatric surgeon. This was not in line with GMC guidance which says doctors should promptly provide or arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs. This did not happen until November 2021. However, at this time investigations with CT scans, MRI scans and other investigations did not identify any obvious cause for Ms S stomach pain.

19. The hernia should have been diagnosed on the scan in September 2019 and this would have been taken into account by both the Trust and the bariatric surgeon who saw her in November 2021. Had the CT scan been correctly reported then it is likely that she would have been advised by the bariatric team to consider surgery to correct it in 2019.

20. Our general surgeon adviser said had the failing not happened, Ms S would likely have had surgery with the bariatric surgeon sometime in 2019 or 2020 depending on waiting list length and COVID restrictions in 2020. It is likely, therefore that she would have had corrective surgery around two years earlier than she did. Our radiologist adviser agrees, if the failing had not happened, surgery could have taken place between 2020 and 2021.

21. Based on what we can see, the Trust did not diagnose the hernia. This is a missed opportunity by the Trust to give the correct diagnosis to Ms S in September 2019. This is based on our radiologist adviser’s advice which says this was a reporting error. A hernia should have been diagnosed in September 2019, and a recommendation should have been made to refer to a bariatric surgeon.

22. The Trust wrote to the GP to specifically say there were no findings of a hernia, but suggested the GP make a referral to a bariatric surgeon. The GP did not make the referral as they did not have all of the available information they needed to make this decision.

23. The Trust had put the decision back into primary care’s hands. In its response the Trust said the fault was with the GP as they did not make the referral as the Trust would have done. But the Trust did not make the referral or give all of the information needed to the GP.

24. Ms S went to Belgium in 2022 to have the corrective surgery. This means although we cannot be sure exactly how long she would have waited, there was at least a years’ delay in her having surgery, and her symptoms, pain and distress would have been relieved sooner. Ms S told us she suffered pain, discomfort, distress and anxiety as she had unexplained symptoms for a significant length of time.

25. Ms S paid for the corrective procedure in Belgium, it cost 1,719.07 Euro. However, some of this was covered by medical insurance. She paid 364.37 Euros which at the time in August 2022 would have been around £300.

26. Our Principles say public bodies should try to offer a remedy such as an apology, explanation, and acknowledgement, action to learn and improve, and financial compensation, or any combination of these.

27. The Trust has not acknowledged that it missed the hernia or that this caused a delay in treatment. It has therefore not taken any action to remedy this failing. Ms S told us she would like the Trust to acknowledge that it did not diagnose her hernia in September 2019 and apologise and give her compensation.

28. As there are failings that led to an impact for Ms S that has not yet been remedied, we will recommend the following actions that the Trust should take to address what happened.

Conclusion

29. Based on the evidence we have seen the Trust did not diagnose the hernia in 2019 or pass on correct information to the GP for it to make an informed decision to investigate further. This meant Ms S had to endure pain until she had her procedure when the pain and discomfort stopped. We hope that our investigation has given Ms S the actions that she wanted to address her complaint.

1. Ms S is understandably concerned that the East Kent Hospitals University NHS Foundation Trust (the Trust) did not diagnose and treat her hernia win 2019, which was identified and treated three years later by a private consultant in Belgium.

2. We found that the Trust has done something wrong when it did not diagnose a hernia in 2019 or give all of the information needed to the GP to make an informed decision to refer to a speciality that could investigate further. As it did not follow the relevant guidelines, we have gone on to consider the affects this had and the outcome for Ms S. We found there were at least a year’s delay in her having surgery, and her symptoms, pain and distress would have been relieved sooner. The delay caused Ms S to suffer pain, discomfort, distress and anxiety, as she had unexplained symptoms for a significant length of time.

3. The Trust has not acknowledged what it got wrong or the impact this had on Ms S and has not taken action to address any of the failings we have found. We recommend the Trust acknowledge what went wrong and apologise for the impact this had for Ms S. We recommend a compensation payment for the impact this had. We also recommend the Trust provide her with an action plan to address the failings we have identified. We uphold this complaint. We are sorry for what Ms S has gone through and hope this will go towards addressing the Trust’s failing and the impact it had on her.

30. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These say that where something has gone wrong that has had an impact, the organisation responsible should take steps to put things right.

31. We uphold this complaint, these are the recommendations we will make. We recommend the Trust write to Ms S to acknowledge something went wrong in diagnosing the hernia and apologise for the pain and suffering this caused her.

32. Our Principles say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat what went wrong. In line with this, we recommend the Trust develop an action plan to address the failings we have identified relating to not diagnosing a hernia. The action plan will include the action, who is responsible for the action, the timescale for completing the action and how it will be monitored to ensure improvement. A copy of the action plan to be shared with Ms S, PHSO, and NHS England.

33. Our Principles say public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

34. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend the Trust pay Ms S: • £300 financial loss payment for the cost to her of the procedure • £950 for the pain and suffering she experienced over the significant period she waited to be diagnosed and treated.