Investigation into the reason for rectal prolapse before first surgery
17. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Miss A to understand the reasons why she did not complain sooner. We have also considered the time the Trust took to respond to Miss A’ complaint.
18. Miss A had her first surgery for rectal prolapse on 12 January 2017. This unfortunately failed soon after. In January 2021, she was diagnosed with Ehlers-Danlos syndrome, and was concerned this diagnosis was not investigated prior to her first surgery. She complained to the Trust on 14 January 2021. We note Miss A contacted PHSO in March 2021 but was advised to wait for the Trust’s response before we could review her case.
19. Miss A was aware she had reason to complain in January 2021. She contacted PHSO again in February 2023. She was advised to pursue the legal route for her complaint which she did, and her first case with us was closed in September 2023. She returned to us in July 2024 as she had found the legal process stressful and no longer wished to pursue it. This case is therefore 2.5 years out of time.
20. As she pursued the legal route on our advice, and returned to us straight away, we have focussed our consideration of the time limit up until she came to us in February 2023, which was one year and one month out of time.
21. We have considered the time the Trust has taken to respond to Miss A. Her complaint in January 2021 was responded to in March 2021. Miss A responded to this letter in April and May 2021, and two local resolution meetings took place in September 2021. The agreed resolution at this meeting was for a second surgeon to take over her care.
22. Although the written summary of these meetings was delayed until 7 January 2022, the resolution had been implemented and the surgeon took over her care immediately, in October 2021.
23. Miss A contacted PHSO in February 2023. The reason she gave for the delay in contacting us, was that a resolution had been agreed, but she now had concerns about the subsequent care and had reason to complain to the Trust again. This second complaint is addressed below.
24. We have considered Miss A’s reasons for not coming to us earlier and the time taken for local resolution. We have not seen enough of a reason to set our time limit aside for this aspect of her complaint. After the Trust concluded its complaint process, there was a delay of a year before Miss A picked up her complaint again.
25. We recognise she might have chosen not to pursue it sooner because further care was ongoing. However, she later changed her mind. Her concerns about the resolution are addressed below. These circumstances do not give a strong reason to justify the delay. We are unlikely to put our time limit to one side when someone could, reasonably, have complained to us sooner.
26. It is important that we apply the time limit consistently across all complaints and this decision is in line with how we apply our discretionary powers to all complaints that we received outside the time limit. We have decided not to consider this complaint further.
Second surgeon refused to provide contingency plan after surgery failed
27. 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 indications that something has gone wrong.
28. Miss A is concerned the surgeon refused to provide any of the options in her contingency plan after surgery in April 2022 failed. She says this left her for a long period with recurrence of her prolapse and no hope for future treatment.
29. Miss A told us how her life was put on hold and she had to defer her university place. She had ongoing distressing symptoms of her prolapse that impacted her daily life. We are sorry to hear of the significant impact this had on her.
30. In February 2022, records indicate the surgeon discussed Miss A’s options after liaising with specialists in Bristol. They discussed and planned a resection suture rectopexy. In this clinic, the surgeon said if Miss A got a recurrence, ‘the next option would probably be an end colostomy and either a perineal procedure or a Thiersch wire to deal with any residual prolapse.’ An end colostomy involves bringing part of the large intestine to the abdomen to form a stoma. The latter two procedures are alternatives for managing a rectal prolapse through the anus rather than through the abdomen.
31. The surgeon did not confirm these procedures would definitely take place if the surgery failed, nor did she give a timescale for providing these.
32. Our adviser referred to the PROSPER trial. This explains ‘there is no accepted standard procedure with over 100 different operations described’. It also states that recurrence rates are high regardless of the operation used. As there are no specific guidelines regarding the choice of operation, we need to consider if the surgeon’s actions were appropriate in what was offered and agreed upon. Our adviser explained the GMC guidance was relevant to the decisions that the surgeon made.
33. In April 2022, the surgeon performed a laparoscopic resection rectopexy and partial mesh removal, with the assistance of a consultant from Bristol. Miss A is not complaining about this procedure.
34. Unfortunately, in May 2022, Miss A still had a low prolapse. The surgeon explained she needed to give the surgical site time to heal before taking further action. She referred her to be seen by specialists in Bristol who had expertise with more complex problems. Miss A did not want treatment outside of the local area, so no further appointments were arranged at Bristol.
35. At a clinic appointment in June 2022, Miss A said she wanted her whole intestine removed. The surgeon explained she could not personally remove her rectum due to the presence of mesh, and that there would be a process to follow for a radical operation. The surgeon referred Miss A to a health psychologist, the irritable bowel syndrome team, and to the local and regional multi-disciplinary team (MDT) meeting.
36. In August 2022, the surgeon again considered conservative management or operative options. She explained the need to discuss Miss A’s care with the MDT and specialist colleagues in Sheffield and Bristol.
37. In September 2022, the surgeon discussed Miss A’s case at the Bristol MDT with many specialists present. The MDT advised no action should be taken until Miss A had proper psychological support in place. They discussed three surgical options, but these would need to take place in a mesh specialist centre. As there were problems accessing psychology locally, but this would be offered at any mesh specialist centre, the surgeon referred Miss A to Sheffield.
38. In the meantime, she tried to refer Miss A to health psychology locally and in Sheffield but due to funding limitations, they were unable to offer care.
39. In February 2023, Miss A saw Gynaecology and Colorectal surgeons in Sheffield on a video consultation. They discussed further surgery but reiterated she would need to see psychology first.
40. The surgeon explained she had done all she could within the limitations of locally funded care and her own expertise. She advised Miss A that having treatment at the specialist centre in Sheffield offered her the best chance of resolving her symptoms.
41. GMC guidance paragraph 15c says ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must refer a patient to another practitioner when this serves the patient’s needs.’
42. Evidence shows the surgeon had extensive conversations with colleagues at specialist centres regarding Miss A’s care, showing good practice consistent with GMC guidance. Our adviser explained rectal prolapse is a difficult condition to treat. The evidence indicates the surgeon considered alternative management plans, acted within the limitations of her abilities and sought specialist advice, appropriately.
43. Our adviser noted various surgical options were discussed. Before offering any specific treatment, it was prudent for the surgeon to discuss and explore all options with the assistance of specialists. The surgeon took steps to pursue different routes for Miss A in a timely manner.
44. GMC guidance paragraph 32 says ‘You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.’
45. GMC guidance paragraph 49a says ‘You must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including their condition, its likely progression and the options for treatment, including associated risks and uncertainties’.
46. Throughout her care, we consider the surgeon’s communication was good with clear comprehensive letters, discussing the risks and benefits, and the steps she was taking to progress Miss A’s care. This was in line with GMC guidance.
47. We understand the frustration Miss A has experienced with delays to her care. We have reviewed her records and seen the Trust has tried to progress her care by seeking input from specialist advice. The evidence indicates the surgeon acted in line with GMC guidance in ensuring Miss A received a good standard of care. Whilst we see Miss A has been impacted due to the time taken to make decisions, we see no indication the Trust has done anything wrong.
Acting on blood tests in August 2022
48. On 16 August 2022, the surgeon requested blood tests to check Miss A’s nutritional status. These tests showed a slightly raised white cell count (WCC) of 14. This can be a marker of infection.
49. Miss A called the surgeon’s secretary on 5 September reporting a distended tummy and being unable to open her bowels. On 7 September, she attended the Trust with a kidney infection.
50. Miss A is concerned that the surgeon’s failure to act on her blood test results led to a delay in diagnosis of her infection, and the need for intravenous antibiotics.
51. GMC guidance paragraph 15 says ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b) promptly provide or arrange suitable advice, investigations or treatment where necessary.’
52. Miss A’s WCC was slightly raised. Our adviser explained in the absence of any symptoms of an infection, no action would be needed. When Miss A called the surgeon’s secretary, she complained of a distended tummy and being unable to open her bowels. These symptoms are not suggestive of a kidney infection.
53. Our adviser explained the surgeon had acted in line with GMC guidance and in a proportionate manner. She ensured the blood tests she requested were normal. In the absence of reported symptoms of an infection, no action was needed for the marginally raised WCC. Miss A had access to her GP or A&E if she had concerns, which we see she did attend.
54. We are sorry to hear of the distress Miss A faced attending A&E with symptoms of her kidney infection. We consider the Trust acted in line with GMC guidance. There was no reason for the surgeon to take action based on the blood test results, and it was appropriate for Miss A to seek advice from her GP or A&E as she did. There are no indications of failing here.
Conclusion 55. Miss A told us of the significant effects these events have had on her physical and emotional wellbeing. She explained how this has affected her daily life, and we recognise she has been through a very difficult time. We are sorry for any further distress this decision may cause. We hope she can be reassured that we have seen no indications the Trust has acted outside of guidance in providing her care.