17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have found the Trust has already done enough to put right the impact of the possible failings we have seen.
Folic Acid Replacement
18. Mrs A complains there was a delay providing a folic acid replacement.
19. Mrs A’s GP asked the surgeon to arrange folic acid IV/IM replacement in September 2023.
20. We can see the surgeon wrote to the neurologist at the Trust at the beginning of March 2024 asking for advice regarding the folic acid IV/IM and dose. They asked the neurologist for their input and a plan for the future.
21. The neurologist said they did not receive this letter. The neurologist saw Mrs A at the end of May 2024 and became aware of the surgeon’s request at this point.
22. The surgeon said they sought advice from multiple specialities about this issue. We cannot see the surgeon requested any advice until after they had referred this issue to the neurologist in March 2024. If the surgeon had sought advice before then, we would have expected to see some record of this as per the GMP which sets out that doctors should keep clear and accurate records, reporting the relevant clinical findings and the decisions made.
23. The records show around June 2024 Mrs A was referred to another Trust’s speciality team who took over this part of her care.
24. Our physician adviser says the GMP, paragraph 15b and c, and 16d apply here. This says, clinicians:
‘(15) …must provide a good standard of practice and care. If they assess, diagnose or treat patients, [they] must:
b) promptly provide or arrange suitable advice, investigations, or treatment where necessary
c) refer a patient to another practitioner when this serves the patient’s needs.
(16) In providing clinical care (they) must… (d) consult colleagues where appropriate’
25. Based on this we would have expected the surgeon, once they received and accepted the referral from Mrs A’s GP, to act promptly and refer the patient to another practitioner if they felt the referral was outside of their remit or area of specialism.
26. We can see the surgeon did refer Mrs A to another practitioner as per the GMP, but they did not act promptly. There was a gap of five months and 18 days between the surgeon receiving the referral and contacting the neurologist.
27. Therefore, because we cannot see the surgeon correctly followed the GMP we consider there is an indication of a failing with this part of the complaint.
28. We have seen after this time there were investigations into folic acid IV/IM. These appeared to be complex. This ended with the Trust finding there was no folic acid IM available in the UK, and it would need to be administered via IV. We cannot hold the Trust responsible for this not being available on IM. There discussions about the merits of administering this via IV before it went ahead with this plan. This part of Mrs A’s care was referred to another Trust.
29. The delay in folic acid replacement treatment was no more than six months. This is because there was a gap of around six months following the referral to the surgeon.
30. Mrs A is concerned the delay getting the folic acid caused further and permanent peripheral neuropathies.
31. Our physician adviser said this delay was unlikely to have had a significant clinical impact to Mrs A’s established peripheral neuropathy. They said it was their impression the neurologist did not think it was too important to Mrs A’s overall condition. This is because we can see from the records the neurologist doubted the benefit of the folic acid IV/IM.
32. This matter was complex and would have always taken the clinicians some time to resolve. Mrs A could not take folic acid orally. Ultimately the Trust could not find a folic acid IM available in the UK and a specialist trust took over this part of Mrs A’s care.
33. This means there would have always been delays to Mrs A getting folic acid. This means any impact this delay had to peripheral neuropathy, if any, could have occurred anyway during the unavoidable delay. Therefore, it would be impossible for us to say any adverse impact to Mrs A’s peripheral neuropathy was specifically linked to the six-month delay.
34. Further, Mrs A has a history of folate deficiency and peripheral neuropathy. This would make it even harder for us to say on balance that any adverse impact to Mrs A’s peripheral neuropathy was linked to the possible six-month delay.
35. Therefore, the impact we consider we can link is the emotional impact of stress and distress, for no more than six months, during the avoidable delay waiting for the folic acid replacement.
36. We measure impact on our severity of injustice scale (our scale). Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity.
37. We consider the impact here is consistent with level two on our scale. Level two says for emotional impact it is ‘…distress, worry, annoyance and similar injustice of the sort which a healthy adult would be expected to deal with on a regular basis, without external support, and which does not impact on the affected person’s day to day functioning, or their ability to live a normal life; for a period from 1-2 weeks to about six months.’
38. Mrs A said, to remedy this complaint, she would like an acknowledgement of wrongdoing, apologies, service improvements, and a financial remedy.
39. The Trust have acknowledged what went wrong and apologised for this. It has said what it will do to avoid this happening again. It shared this issue with the surgeon for reflection. It also said it reminded its clinicians it can get support from the Medical Director’s office for similar matters. These actions are in line with NHS Complaint Standards.
40. The Trust has also offered Mrs A a payment of £400 in recognition of the distress she experienced for the delay and other complaint parts we go on to discuss below. This is consistent with level two on our scale. We are pleased the Trust’s financial remedy is towards the upper end of this range, reflecting the lengthy delay.
41. We consider the Trust has taken appropriate action to remedy this complaint. Therefore, we should not consider this part of the complaint any further.
Unprofessional conduct
42. Mrs A also complains about the conduct of the surgeon and neurologist. Mrs A says the surgeon and neurologist blamed each other for delays in her care and called each other unprofessional. She said this happened both face-to-face and during phone consultations.
43. As we were not present we cannot know what exactly was said during the consultations. We have seen emails between the two clinicians which shows evidence of a disagreement between them. Given these emails contain accusations of wrongdoings, along with Mrs A’s recollection, we consider on balance (more likely than not) the clinicians may have appeared unprofessional in Mrs A’s presence.
44. We consider this is likely contrary to GMP paragraph one which says, ‘good doctors… establish and maintain good relationships with patients and colleagues’. The evidence of the above unprofessional disagreement shows this was likely not followed.
45. Any delays this caused would have been minimal, because this matter was complex and would have taken time to resolve in any event. This undoubtably exacerbated the emotional distress experienced by Mrs A.
46. The Trust acknowledged this behaviour and apologised for it. It also said what it would do to avoid this happening again. It said it discussed this matter with the clinicians involved to ensure reflection and learning. We are pleased to see the Trust has taken steps to remedy this part of the complaint. This is in line with NHS Complaint Standards. We consider this, along with the financial remedy, is enough to remedy this part of the complaint. Therefore, we will not consider this part of the complaint any further.
Surgery to dilate stoma
47. The Trust recommended Mrs A have the surgery to dilate her stoma during her admission at the beginning of September 2023. Mrs A did not have this surgery until four months later.
48. Mrs A said because of the issues with her stoma she could not eat solid food.
49. Our surgeon adviser suggests such surgeries would be given priority ‘P3’. NHS guidance says, at appendix D, ‘waiting list prioritisation’, P3 surgeries should have a wait time of no more than three months. Our adviser said the four-month wait was excessive given Mrs A was on a liquid diet and was previously admitted to hospital due to this issue.
50. The Trust said at the time there was a backlog of more urgent surgeries for patients with cancer. It said it has checked Mrs A’s four month wait. There was a large amount of theatre time during December 2023 allocated to patients on cancer pathways or to those in hospital who needed urgent surgeries.
51. We consider there is an indication something went wrong here, because Mrs A’s surgery wait was a month longer than we would have expected. That said, we appreciate there were mitigations at the time as the Trust had other priority surgeries to complete. In a perfect world Mrs A would have had this surgery within three months. Unfortunately, the Trust had a large backlog of more urgent surgeries.
52. We accept the Trust’s rationale about treatment delays due to demand on its service. Trusts can only do so much when they have large demands on their service. The Trust unfortunately cannot treat everyone at the same time. In this environment, the Trust managed to limit the delay to a month rather than longer.
53. We understand how difficult a time this must have been for Mrs A. On top of already experiencing the distress of the events complained about, Mrs A could not eat solid food while she waited for this surgery. We acknowledge the added distress this wait would have caused Mrs A.
54. The Trust has acknowledged this delay and apologised for it. It also said what it will do to help reduce wait times in the future. Along with the financial remedy, we consider the Trust has already remedied this part of the complaint in line with NHS Complaint Standards. There is nothing more we would recommend that the Trust has not already done. Therefore, we should not consider this part of the complaint any further.
Blood Tests
55. At the beginning of June 2024, the surgeon requested blood tests for various factors, including B12 and folic acid. This test was not able to be done. The Trust arranged further blood tests, this was done at the end of June 2024.
56. We can see these blood tests are incomplete as they do not include B12 or folic acid levels. There is therefore an indication something has gone wrong as the Trust did not do something it said it was going to do.
57. We consider the impact of any possible failing here would be minimal, around level one on our scale, if there was any at all. This is because, when the blood test was done, Mrs A was at the specialist team at another Trust which took control of this part of her care.
58. We can see there was a folic acid test done in December 2023. Our physician adviser says it would have been important to do a repeat test when her treatment started. This treatment was now being done at another Trust. If this test was done and acted on at the other Trust, then the missed tests were no longer important to Mrs A’s care.
59. We appreciate the distress and frustration this will have caused Mrs A, especially after everything else that proceeded it.
60. The Trust explained it has changed its electronic request system. It says this change should reduce the likelihood of another patient experiencing a similar issue. It then apologised this was not the case for Mrs A at the time she had her blood tests done. We consider this is enough to remedy the impact which likely sits at level one. Our scale says an apology is usually enough to remedy this level of impact.
61. We consider the actions taken are in line with NHS Complaint Standards. There is nothing more we would recommend with this part of the complaint, and we should not consider this part of the complaint any further.
62. We considered the overall impact of the above four complaint components. We consider the overall impact also sits at level two on our scale. This is because the length of impact does not exceed six months as explained above. Therefore, we consider the Trust’s actions and plan, which we consider is in line with level two on our scale, remedies all the above components collectively. We should therefore not consider any of the above complaint further.
Did not expedite stoma surgery
63. 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 found any indications that something has gone wrong.
64. Mrs A says a doctor told her, the morning after the dilation surgery at the beginning of January 2024, in the presence of a nurse, she required further surgery to refashion the stoma (improve function by adjusting its position or structure). They told her this surgery would be expedited. Mrs A says the Trust did not include this in the discharge summary and did not expedite this surgery as it was not done until the middle of March 2024.
65. We cannot see a record of such a discussion in Mrs A’s records.
66. We have seen the surgeon’s plan recorded in their letter to Mrs A’s GP in October 2023. This set out it was the initial plan to first try the more conservative surgery of dilation because of the associated risks with the more invasive refashioning procedure, but this was a last resort if the dilation did not work as intended.
67. We can see the dilation surgery was successful without complications and there was a plan to review in follow-up clinic in ‘due course’.
68. We can see Mrs A was seen in the clinic at the end of February 2024. Mrs A was ‘still struggling’ with her stoma. The more invasive option of refashioning was discussed. Mrs A agreed with this option. We can see an urgent referral for this procedure was made the same day.
69. Our surgeon adviser says this would be P2 in the NHS guidance, which is an appointment within one month. We can see the surgery occurred in March 2024 within a month of the referral.
70. Our surgeon adviser says the GMP is relevant here. The Trust’s plan to review Mrs A following the dilation surgery was reasonable and in line with paragraph 15 of the GMP. Then the referral was made and acted within the expected time frames.
71. The evidence shows the Trust had a clear plan to treat Mrs A which it followed. We consider the Trust took appropriate action. It may be Mrs A misunderstood the clinician when discussing the possible next steps following review. That is not to dismiss Mrs A’s recollection and how stressful a time this must have been for her. Clearly Mrs A believed she was advised she needed this surgery. Having to wait so long for this to happen, at an already difficult time would have been distressing.
72. Considering all the above, we have not seen an indication anything went wrong with this part of Mrs A’s care. Therefore, we will not consider this part of her complaint any further.
73. With this decision we are not intending to dismiss or diminish the impact Mrs A experienced. It was clear she went through a very difficult time and we recognise this was a very stressful and distressing time in Mrs A’s life.