Diagnosis 18. Mrs R says the Trust misdiagnosed her with a UTI instead of kidney stones in April 2022. She is understandably concerned as she returned to the Trust several times and was diagnosed with kidney stones. It is clear from what she has told us that this caused her significant pain and impacted her day-to-day life. Which we are sorry to hear about.
19. NHS website says symptoms of UTI’s include blood in the urine and lower tummy pain. It explains pregnancy increases the risk of UTI’s.
20. We can see from Mrs R’s medical records she attended the Trust’s ED on 21 April with abdominal pain and vaginal bleeding. It carried out a full blood test including a kidney function test which was normal. It also carried out a urine test which showed she had blood in her urine. It suspected she had a UTI and discharged her with antibiotics.
21. She returned to its ED on 24 April with worsening abdominal pain. It carried out an ultrasound scan which identified a small stone in her right kidney. The Trust’s urology team relieved Mrs R’s symptoms with a catheter on 25 April and discharged her on 27 April after it had shown her how to self-catheterise. It planned to carry out a further ultrasound in one month.
22. Our adviser explains Mrs R’s blood tests showed her kidney function was normal and based on her symptoms it was reasonable to treat her for a UTI. Therefore, the Trust did not get anything wrong when it diagnosed her with a UTI based on her symptoms and test results.
23. We recognise Mrs R is concerned she could have been diagnosed with kidney stones earlier, as she received this diagnosis two days later. Our adviser explains the combination of intermittent symptoms and normal blood tests means there were not opportunities for earlier diagnosis. Therefore, we cannot say the Trust missed an opportunity to diagnose and treat her kidney stones earlier.
24. We hope this information reassures Mrs R that the Trust did not get anything wrong when it diagnosed her with a UTI on 21 April. Therefore, we do not uphold this part of her complaint.
Surgery 25. Mrs R says the Trust incorrectly carried out a procedure to insert a nephrostomy tube for her kidney stones in May 2022 and left part of the tube in her kidney following surgery to remove it in June 2022. It is understandable Mrs R feels something went wrong with the procedure as she had lots of complications afterwards. From what she has told us it is clear it was a painful and traumatic experience for her. We are sorry to hear Mrs R continued to experience continued bleeding, chronic thrush and the tube got blocked on two occasions.
26. NICE guidance says offer surgical treatment to adults with ureteric stones and renal colic within 48 hours of diagnosis or readmission, if pain is ongoing and not tolerated. It explains surgery options include percutaneous nephrolithotomy and ureteroscopy. Percutaneous nephrolithotomy is the placement of a small, flexible tube through your skin into your kidney to drain your urine. Ureteroscopy involves the passage of a small telescope, called a ureteroscope, through the urethra and bladder and up the ureter to the point where the stone is located, this is usually carried out under general anaesthetic.
27. We can see from Mrs R’s medical records she attended the Trust on 12 May with ongoing abdominal pain. The Trust carried out an ultrasound scan which identified a kidney stone in her left kidney and bilateral hydronephrosis. This is a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them. It carried out a percutaneous nephrolithotomy to relieve Mrs R’s symptoms 13 May.
28. Our adviser explains percutaneous nephrolithotomy in a pregnant patient with persistent pain and a suspected obstructing ureteric stone is the correct management. They went on to say the alternative treatment would be an indwelling stent. However, they explained percutaneous nephrolithotomy would be the treatment of choice as it minimises the risk to patient of repeat anaesthesia during pregnancy.
29. The Trust has followed NICE guidelines as we can see it carried out the procedure within 48 hours of Mrs R presenting with pain at its ED. We understand Mrs R thinks something went wrong during the procedure. As we were not present during the events, we cannot say the Trust got anything wrong when it carried out the percutaneous nephrolithotomy. We hope she is reassured that the Trust acted in her best interests to relieve her symptoms and minimise the risk to her and her unborn child.
30. We have gone on to look at Mrs R’s concerns about part of the tip that the Trust left in her kidney when the nephrostomy tube was removed.
31. We can see Mrs R attended the Trust on 21 June as the nephrostomy tube was blocked. It changed the tube, and it reported she passed a small stone shortly afterwards. The Trust carried out an ultrasound scan on 23 June which confirmed the kidney stones had passed and her hydronephrosis had resolved. It attempted to remove the nephrostomy tube under local anaesthetic but was not successful.
32. On 27 June the Trust carried out a procedure on Mrs R under general anaesthetic to remove the nephrostomy tube. The tip of the tube was encrusted and broke during the procedure. The Trust attempted to remove the tip which was unsuccessful. It planned to remove the tip once she had given birth due to the risks of a prolonged procedure during pregnancy.
33. Our adviser explains it is rare for a nephrostomy tube to snap during removal. It would suggest the nephrostomy tube tip was heavily encrusted, which pregnant women are more likely to experience. They went on to explain it is safer to return after the patient has delivered their baby, as there is less risk of preterm labour and radiation exposure to the baby.
34. There is no guidance on what an organisation should do if a nephrostomy tube snaps during removal. Therefore, we cannot say the Trust got anything wrong with the removal or management of the tube tip following the procedure. We can see the Trust in its final response have acknowledged the tube tip was left in following the procedure and explained the reason and risks to her at the time. We can also see it planned to monitor the tube tip in the following months.
35. We do not uphold this part of Mrs R’s complaint as we can see the Trust’s decisions to carry out the procedure was in line with NICE guidelines. We recognise the tube tip being left in place would have been distressing for her. We can see the Trust made this decision in her best interests as she was still pregnant at the time and continued to monitor her. We can also see the Trust has acknowledged the anxiety this may have caused her.
36. We hope this reassures her that the Trust has taken her complaint.
Medication 37. Mrs R says the Trust gave her an incorrect dosage of anti-biotics in January 2023 for an abscess she developed after surgery in December 2022 to remove the rest of the tube. We are sorry to hear she continued to experience complications following her nephrostomy tube removal. Understandably this was a distressing period for her.
38. Mrs R’s records show she attended the Trust on 27 December with worsening pain following surgery at another Trust to remove the nephrostomy tube tip. During the admission it identified an abscess at the site where the tube tip was. The Trust provided treatment and discharged her on 29 December. The Trust readmitted her on 3 January with continued pain. It drained the abscess and took samples of the bacteria from the abscess. It treated her with antibiotics and discharged her on 11 January with a 21-day course of 250mg tablets of flucloxacillin. Flucloxacillin is an antibiotic used to treat infections.
39. BNF guidance says prescribe 250mg to 500mg of flucloxacillin four times per day for infections in adults. Therefore, the Trust followed BNF guidance to prescribe a 250mg dose.
40. We understand the confusion it caused Mrs R when the Trust contacted her following discharge to increase the dose of flucloxacillin. Our adviser explains while awaiting results of bacteria, it is reasonable to treat with standard dose of antibiotics. They went on to explain it is reasonable to increase the dose once there is proven evidence of bacterial infection.
41. While we can see the Trust has followed the BNF guidance we also wanted to reassure Mrs R that our adviser explains the delay of increasing her antibiotics prescription would not have caused any clinical impact. They also said it is important to start antibiotics as early as possible for suspected infections to prevent severe complications, such as sepsis, especially in patients with complicated urinary tract abscesses.
42. The Trust followed BNF guidelines and prescribed within the recommended dose. There is nothing specific in the guidelines which indicates when or if the dose should be increased. Therefore, we cannot say it got anything wrong when it prescribed a lower dose and later increased it.
43. We hope this provides Mrs R with some reassurance that the Trust followed guidance and did not get anything wrong. We do not uphold this part of complaint.
Conclusion 44. Based on all of the evidence we have considered we have not found the Trust got anything wrong with the way it managed Mrs R’s care in relation to her kidney stones and the actions following the removal of the nephrostomy tube. We therefore do not uphold her complaint. We recognise this experience must have been a difficult period for Mrs R. We do not wish to underestimate the impact this has had on her and her family.