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East Kent Hospitals University NHS Foundation Trust

P-003611 · Statement · Decision date: 24 June 2025 · View East Kent Hospitals University NHS Foundation Trust scorecard
Transfer, discharge and aftercare Care and discharge planning
Complaint (AI summary)
Mrs A complained East Kent Hospitals University NHS Foundation Trust discharged her too soon after colon surgery, leading to an undetected wound infection that ruptured, required further surgery, and delayed chemotherapy.
Outcome (AI summary)
Complaint closed. No indication was found that anything went wrong in Mrs A's care.

Full decision details

The Complaint

3. Mrs A complains the Trust discharged her only three days after right hemicolectomy surgery (removal of the right half of the colon) on 5 April 2023. Mrs A says this was too soon.

4. Mrs A says because of this, the Trust did not recognise her wound was becoming infected, leading it to rupture on 16 April and ruining her carpet and mattress. Mrs A says for the next eight months she was in a lot of pain, had to attend her GP Practice every day to have the wound packed and had a wound vacuum pump attached to her.

5. Mrs A says in September she had to have further surgery to lay open the wound, which left her abdomen scarred and disfigured. She also says she now cannot have chemotherapy for her neuroendocrine tumours because she has an open wound.

6. As outcomes to her complaint Mrs A would like an apology and financial reimbursement for her expenditures.

Background

7. Mrs A was diagnosed with colon cancer in early 2023. On 5 April 2023, she had a right hemicolectomy surgery. This is a surgical procedure to remove part of the colon (also known as the large bowel, or large intestine). That evening, and the following morning on 6 April, she declined pain medication. The records note she slept well, and her observations were all normal.

8. She was reviewed by a physiotherapist at 9.30am and 10.30am. They documented that Mrs A was independent with her mobility, noting she was able to stand and walk around her bed to an armchair alone. They also noted that Mrs A had no concerns about going home and managing her own care. She was fully independent and lived with her husband. The physiotherapist noted her activity levels; that she was playing tennis five times per week.

9. During the day on 6 April, Mrs A continued to mobilise to the toilet and had opened her bowels. She declined medication, and her observations were normal.

10. That evening, nursing notes show Mrs A reported she was not in pain at all, and she was not using her patient-controlled analgesia (PCA). A PCA allows a patient to self-administer pain medication through an IV pump. Mrs A asked the Trust to disconnect her PCA, which it did at around 8.30pm. Mrs A declined her night medication.

11. At 8.40am on 7 April, a doctor reviewed her and noted she was well, and was eating, drinking and mobilising. She declined her regular pain relief this day. The Trust removed the drains from her wound and noted the wound was healthy with no sign of infection. All her observations were normal on this day.

12. Mrs A declined night medication again this evening. She was not in pain, was still opening her bowels and she was comfortable.

13. At 8.50am on 8 April a doctor reviewed her and noted she had no pain, and she told them she felt well. All her observations were normal. The Trust discharged her on this day.

14. Mrs A attended A&E on 14 April due to abdominal pain. The Trust arranged a scan for 18 April, but on 17 April, Mrs A returned to the hospital because she had woken up during the night with fluid discharging from the wound. A CT scan showed inflammation along the surgical wound and a collection of fluid. The Trust aspirated the wound (used a needle to remove fluid) and prescribed antibiotics.

15. On 21 April Mrs A returned for another aspiration, explaining that the wound had been discharging through the week. She had a review on 24 April where a vacuum-assisted closure (VAC) dressing was applied. This is a type of sealed dressing which applies controlled suction to the wound to remove excess fluid.

16. Mrs A was regularly reviewed throughout the year. On 13 September, she had to have the wound re-opened to re-explore the abdomen as her wound continued to discharge fluid, despite the wound infection having healed. This surgery left her with a significant scar.

Findings

20. 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.

21. Mrs A believes the Trust discharged her too soon after her surgery on 5 April. She says she was originally told she would be kept in for seven to ten days but was discharged after three days. Mrs A says if the Trust kept her in for longer, it would have identified the issue earlier and prevented it, or treated it sooner, and this series of events and scarring would not have occurred.

22. The Trust says Mrs A likely had an infected seroma after surgery in April. This is where fluid collects under the skin after surgery and becomes infected with bacteria.

23. There is no medical standard or guideline on when a patient should be discharged from hospital following hemicolectomy surgery. Our adviser explains the length of a patients stay in hospital after this operation typically ranges from three to seven days. Although some services send patients home after one or two days if they are well enough to do so.

24. The GMC’s Good Medical Practice says doctors must provide a good standard of care. If doctors treat patients, they must adequately assess the patient’s condition. Our adviser explains it is important that the patient is considered safe to be discharged.

25. Our adviser explained it is general practice to monitor a number of signs to tell if a patient is safe to be discharged. These signs include normal observations of heart rate, blood pressure, respiratory rate, and temperature, and whether they are tolerating oral liquids and some soft diet. It also includes pain after surgery; it is usually adequate if oral painkillers are enough to control the patient’s pain. It is not absolutely necessary to wait until a patient is opening their bowel.

26. A Trust will also consider a patient’s social circumstances, such as whether they live alone and are able to look after themselves.

27. From Mrs A’s procedure until the date of her discharge, all her observations were within normal ranges. She was tolerating oral liquids, and she was eating and drinking well. Her pain was well controlled, with her not using her PCA and declining most medications. Her bowels were also opening, and she was independently mobile. All of these signs showed Mrs A was medically fit for discharge.

28. Moreover, when the Trust removed the drains from Mrs A’s wound, the wound was healthy and there were no signs of infection. Mrs A also reported to feel well, she had no concerns about her discharge and was able to look after herself independently at home.

29. The Trust therefore adequately assessed Mrs A in line with the GMC’s Good Medical Practice after her surgery. From the outcome of these assessments, there was no reason for Mrs A to stay in hospital any longer.

30. Cancer Research website explains that infection of the wound is a known risk of surgery for colon cancer, and that this may require another operation. Clinical studies, such as studies 1 and 2 noted above, also shows that wound infection is a known common complication, and in study 2, 49% of those who developed a wound infection, did so after they were discharged from hospital.

31. Our adviser explained that staying in hospital therefore would not have prevented Mrs A’s wound infection as it is common for these to present after discharge from hospital. There is also a risk of getting an infection the longer a patient stays in hospital.

32. We appreciate this was painful for Mrs A and took a long time to heal. We hope it brings her some reassurance that it is unlikely this could have been avoided if she stayed in hospital longer. Wound infection is a recognised complication risk of bowel surgery. We have seen no indications anything went wrong in the Trust’s actions. For this reason, we will take no further action on this.

Our Decision

1. We have carefully considered Mrs A’s complaint about East Kent Hospitals University NHS Foundation Trust (the Trust). We have seen no indication that anything went wrong in her care. Because of this, we will not be considering Mrs A’s complaint further.

2. We were terribly sorry to hear of the experience Mrs A had after her hemicolectomy surgery in April 2023. We appreciate this had a significant impact on her over the following months and has left her with considerable scarring. We understand this has been extremely distressing for Mrs A.

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