Decision to move Mr F’s surgery to last on the operating list
16. On the day of Mr F’s surgery, the Trust explained there was a breakdown in communication between the booking team and clinicians. This meant before surgery he had not been listed correctly according to the Trust’s policies. On the day, it moved his position in the operating list to last.
17. In its complaint response, the Trust said its policies do not say people living with HIV should go to the end of the operating list, but all infected patients should be scheduled last on the list.
18. It said each case is treated with precaution because of possible bloodborne viruses (BBVs - viruses that can spread from one person to another through blood and some bodily fluids, like HIV). Its policies at the time also said cases of confirmed risk of infection need extra measures to be taken (to deep clean the surgical theatre, for example) and these take more time.
19. We considered the policies the Trust had at the time.
20. The Trust’s original theatre policy was used to support how operating theatres run. The Trust’s original operating procedure was used with this to make sure all patients booked into theatre sessions are given a slot in line with clinical priority.
21. At the time, these policies said theatre lists should be made at least 24 hours before surgery. The theatre team leader would access the list at 4pm the day before surgery. It also said all infected patients should be scheduled last on the list.
22. The Trust referred us to its BBVs policy which covers the infection prevention and control precautions needed to protect healthcare workers from BBVs. This said patients with HIV infection do not need routine isolation but must follow the Trust’s original isolation policy.
23. The Trust’s original isolation policy said patients with known or suspected infections must as far as possible be seen at the end of the list and not be left in the waiting areas. It said this will allow for cleaning of the environment and equipment after the appointment and reduce the risks to other patients.
24. This meant on the day of Mr F’s surgery, the Trust made its decision because it thought Mr F fell into the infected patient category as he has HIV. In line with its policies, it decided he should be put last on the operating list.
25. We reviewed the decision made by the Trust with the help of our adviser.
26. Our adviser explained the general principle is every surgical patient is treated as if they have HIV, and therefore precautions taken during and after surgery are enough to protect all patients and staff. They explained universal precautions (procedures that are used widely) are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient. They are designed to protect and prevent infections from spreading in patients and staff and are used worldwide.
27. The concept of putting a patient at the end of an operating list with the aim of deep cleaning at the end usually relates to patients with a high-risk bacterial infection like MRSA (a type of bacteria that is resistant to several widely used antibiotics). This would not relate to a person who has HIV and is getting treatment.
28. The DoH code of practice states good infection prevention and cleanliness is essential to make sure people who use health and social care services get safe and effective care. Prevention of infection and cleanliness must be part of everyday practice for everyone all the time. This includes wearing gloves and other protective clothing, safe handling and disposal of sharps, and steps to reduce the risks during surgical procedures.
29. Standard infection precautions should always be used by staff, in all care settings, for all patients whether infection is known to be present or not. They include basic principles of infection and prevention to reduce the risk of transmission of bacteria, fungi and viruses from one person to another. This includes environmental hygiene, hand hygiene and use of personal protective equipment.
30. Perioperative guidance explains staff employed in the perioperative setting (time of a patient’s surgical procedure) are aware of the risk of transmission of BBVs and keep to standard precautions for infection prevention and control for all patient care.
31. It goes on to say it is possible to be infected with certain BBVs without symptoms and certain procedures have a higher risk of transmission of viruses between patients and staff. This means every patient should be considered a potential carrier of these viruses, and standard infection control precautions should be used during all patient care to reduce any potential risk of transmission.
32. The guidance we have seen suggests that patients should be treated the same regardless of if they have HIV or not, and infection prevention precautions should be used consistently with everyone.
33. The decision to move Mr F to last on the operating list was made because he has HIV. Although the Trust says this decision was in line with its policies at the time, these did not define what an infected patient was, meaning this was left open to interpretation. This means Mr F was classed as an infected patient.
34. Considering the evidence, we do not think the Trust’s decision to move Mr F’s surgery to last on the operating list was in line with the guidance and there was no reason for his surgery time to be moved. We think Mr F was treated inappropriately when this happened and this is a failing.
Impact of the failing
35. We considered how this failing affected Mr F.
36. We can see he was ready to have surgery first and because the Trust moved him to last on the list (before he was about to go to theatre), this made him feel unprepared and anxious. Mr F has a history of anxiety and this stressful situation made it worse.
37. We can also see how the reason for the change in surgery time caused him to feel upset and humiliated because the Trust felt he was an infected patient. We can see how this caused him to lose confidence in the Trust and to worry about his future care.
38. We recognise how hard this situation was for Mr F and we are sorry he went through this experience.
Action taken by the Trust in response to Mr F’s complaint
39. Our principles say where maladministration (fault) or poor service has led to injustice or hardship, public organisations should try to offer a solution that returns the complainant to the position they would have been in. If that is not possible, it should compensate them appropriately. We want organisations to be fair and to take responsibility, acknowledge failings and apologise for them, and to use the opportunity to improve their services.
40. We considered the actions taken by the Trust as a result of Mr F’s complaint.
41. The Trust apologised to Mr F for the original decision it made to put him first on the operating list, as this was not in line with the policies it had at that time. The Trust has given us evidence of the updates it has made to its policies. The updated policies no longer say infected patients will go at the end of the operating list. The Trust also offered an apology for the distress this caused to patients affected by it.
42. The Trust’s updated theatre policy and operating procedure now say it is the surgeon’s responsibility to make sure their theatre list is completed two to four weeks before the date of surgery. It says it is the surgeon’s responsibility to make sure patients are listed correctly.
43. It also now says when preparing the operating list, consideration of individual patient clinical need, safety and efficiency must be made. It does not say infected patients should be put last on the list.
44. The Trust’s updated isolation policy has also now been changed and explains which common infections are covered by the policy and what kind of isolation is needed.
45. The Trust explained the complaint has been shared with staff in the surgical teams and it has also verbally told staff about the changes to the policies.
46. We do not think the Trust has done enough. Mr F complains the Trust moved him to the end of the list because of his HIV (despite what its policies said at that time). The Trust has failed to accept this part of the complaint and it has not apologised to Mr F for treating him differently because of his HIV status when it made its decision.
47. We now ask the Trust to acknowledge and apologise to Mr F for making the decision to move his surgery time due to him having HIV, when this was not appropriate.
48. We considered whether the changes made to the Trust’s policies are in line with current guidance.
49. The NHS England manual explains that to protect effectively against infection risks, standard infection control measures must be used consistently by all staff. And as part of infection prevention measures, organisations should assess patients for infection risk. This assessment should influence decisions in line with clinical care and needs.
50. It gives examples of patients who may present a cross-infection risk like those with diarrhoea or vomiting, those positive with a multi-drug resistant organism (like MRSA) and patients who have been an inpatient in the UK or abroad.
51. Yan’s research paper states when doing surgery on patients with HIV, clinicians should use standard universal surgical precautions to prevent exposure to blood and bodily fluids.
52. We recognise the Trust has made some changes to its policies, but we think these are not clear enough and the same situation could happen with another patient with HIV.
53. This is because the Trust’s updated theatre policy and operating procedure do not explain how patients should be assessed for infection risk and how this will influence where they are put on the operating list. It simply says the surgeon responsible must identify any patients who should be put last on the list, like those with wound infections. This means another surgeon reading the policies may read this differently to someone else, leading to the same situation Mr F experienced.
54. The updated Trust's isolation policy also groups AIDS (late stage of HIV infection that happens when the body’s immune system is badly damaged because of the virus) and HIV together and is not specific about which situations mean a patient should be isolated. It does not consider that a person with HIV may be on medication that supresses their viral load (HIV virus in the blood) to a level that makes it undetectable, which means it is low enough not to show up on a test (taken from the NHS website). Evidence supports that an undetectable viral load makes HIV untransmissible (it cannot spread to someone else).
55. The guidelines above say every patient is treated the same and do not say anyone living with HIV should be treated differently when listed for surgery. We do not think that, as they are, the Trust’s policies will be used consistently by everyone.
56. We think the Trust’s should make its policies clearer to make sure the same situation does not happen to another similar patient.
57. We ask the Trust to review its policies and make improvements to make sure patients living with HIV are treated the same as other patients. These improvements should also be shared with staff.