16. 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.
Treatment and communication
17. Miss F said the Trust’s urology team did not keep her updated or respond to her requests for help in treating her vulvovaginal infection when her symptoms worsened in August 2022.
18. Miss F told us she was experiencing significant pain while waiting for the Trust to liaise with other specialists and update her, and she felt the Trust was ignoring her requests for help.
19. The Trust explained in its response that Miss F’s main symptoms (vaginal candidiasis and ongoing chronic pain) had been discussed in Miss F’s consultations and did not appear to be urological, particularly in the context of a normal cystoscopy and prior imaging that had taken place in November 2022.
20. The Trust said it had sent referrals to the infectious disease and pain management services but recognised it was frustrating for Miss F to feel there were several different specialists responsible for her care, and none were taking the lead.
21. GMC Good medical practice explains:
‘Continuity of care is important for all patients, but especially those who may struggle to navigate their healthcare journey or advocate for themselves. Continuity is particularly important when care is shared between teams, between different members of the same team, or when patients are transferred between care providers.
You must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required.
You must share information with patients about:
• the progress of their care • who is responsible for which aspect of their care • the name of the lead clinician or team with overall responsibility for their care.’
22. After Miss F’s initial consultation in August 2022, the Trust held a urology multi-disciplinary team meeting (MDT) to discuss her care. Following the MDT, the Trust spoke to Miss F by phone and explained it had contacted the infectious disease team and were waiting for a response. The Trust said it would contact Miss F once it had a response and a plan in place.
23. Miss F then contacted the Trust’s Patient Advice and Liaison Service (PALS) in October as she had not received any update. PALS referred Miss F’s case to the urology consultant. However, it said an administrative error meant the consultant’s reply was then not passed on to Miss F. The Trust apologised for this.
24. The Trust discussed Miss F’s case again in a further MDT with infectious diseases and microbiology in November 2022 to agree a plan for Miss F’s care moving forward.
25. Miss F then attended her planned appointment in November 2022 and had her SPC changed and Botox injection. The Trust also carried out a CT scan which showed normal kidneys and bladder, and a cystoscopy which was normal with no signs of bleeding or urothelial lesions (a cancer that develops in the inside of the urinary tract).
26. During Miss F’s admission for her appointment, an infectious diseases consultant spoke with her and offered to see her as an outpatient with a fungal specialist, as it appeared Miss F’s symptoms were driven mainly by vaginal candidiasis which was sending pain through the pelvis.
27. European Urology association guidelines on urological infections say to treat symptomatic catheter-associated urinary tract infection (UTIs occurring in a person whose urinary tract is currently catheterised) according to the recommendations for systemic infections.
28. These recommendations include urinalysis and culture testing, routine blood tests and cultures, imaging and antimicrobial therapy (medications to treat infections caused by bacteria, fungi and viruses).
29. Our urology adviser said between August and November 2022, the Trust prescribed appropriate antibiotics to Miss F according to the culture and sensitivity results it had carried out. Our adviser said the Trust also carried out a cystoscopy and a CT scan in line with the guidelines to exclude reversible causes of Miss F’s symptoms.
30. The adviser added that Miss F’s conditions are multiple, complex and chronic, and not all of her symptoms were attributable to infection. The adviser said it was appropriate for the Trust, in line with GMC guidelines, to manage her with a multidisciplinary team to decide the best course of action.
31. Following Miss F’s appointment in November 2022, the Trust held a further MDT with urology consultants, nursing specialists and radiologists. It agreed there was no urological cause for Miss F’s pain and no abnormality of the urological tract on the imaging the Trust had carried out.
32. Therefore, the Trust agreed there was no surgical solution from a urological perspective and it would refer Miss F’s case to pain management and infectious diseases teams, while continuing to do her SPC changes and Botox injections within urology.
33. GMC Good medical practice also states:
‘The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about:
• their condition(s), likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition(s), including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.’
34. We recognise Miss F felt the relevant teams at the Trust were not communicating with each other and were therefore not updating her on her treatment plan. We appreciate once Miss F had contacted PALS she was expecting an update, and when this did not come, it may have added to her distress.
35. The evidence we have seen shows the Trust was continuing to regularly communicate within teams and care providers to ensure the best continuity of care for Miss F. The urology service at the Trust appropriately assessed and investigated Miss F’s symptoms in line with relevant guidelines. We have seen no indications the Trust have done anything wrong.
Behaviour warning and discharge
36. Miss F said the Trust gave her a behaviour warning without explaining why and then wrongly discharged her from its care.
37. The Trust said it had tried to manage Miss F’s level of communication with the clinical team, but this had continued despite the behaviour letter it had issued to her in February 2023.
38. The Trust said as Miss F had expressed on multiple occasions that she did not trust its clinical team to care for her it did not believe there was a service the urology department could offer her that she would be content with.
39. The Trust has a policy on dealing with patient and visitor behaviour. The policy defines abusive behaviour as a broad range of behaviours which can include excessive demands on individual clinicians and/or services including frequent communications containing repeat allegations and/or demands for immediate attention.
40. The Trust’s policy has a three-stage process which includes a verbal warning, written warning and finally, exclusion from the Trust.
41. Along with the Trust’s response to Miss F’s complaint in February 2023, it sent Miss F a letter explaining that she had been reluctant to accept that her expectations for contact to the clinical team could not be met.
42. The letter set out a plan for Miss F’s future communication with the urology service. This plan included routine appointments with the urology service including dates for repeat Botox. The letter asked Miss F to contact the administrative team at the service with queries regarding appointments or surgical dates, and any routine clinical question for the urology team could be brought to the next appointment.
43. The letter further explained Miss F should attend the local Emergency Department, contact NHS 111 or contact her GP with any urgent clinical questions, depending on the urgency. It also provided contact details for the pain management and infectious diseases team for Miss F to follow up with these teams directly.
44. We recognise Miss F was frustrated at what she felt was the lack of progress from the Trust in responding to her requests for information. Miss F was continuing to contact the Trust during this time via what the Trust considered to be inappropriate avenues.
45. We consider the Trust acted in line with its policy by trying to agree a plan with Miss F to ensure a consistency of communication via the most appropriate channels, given how multi-faceted her issues were.
46. We do not consider there are any indications the Trust did anything wrong in issuing this letter.
47. After receiving the behaviour letter, along with the Trust’s complaint response, Miss F went back to the Trust to raise outstanding concerns and discrepancies that she felt had not been addressed in the response.
48. The Trust arranged a local resolution meeting for Miss F which took place in September 2023. The Trust explained the purpose of the meeting was to agree on a suitable way forward to progress Miss F’s care.
49. During the meeting, the Trust said Miss F was aggressive in tone and the staff/patient relationship had broken down to the point where Miss F had expressed on multiple occasions that she did not trust the clinical care team to care for her.
50. Miss F said she was not aggressive during the meeting, and her anxiety was affecting her so that her hands were shaking. Miss F said she felt she was bullied and intimidated and the Trust did not tell her she could bring someone along.
51. We were not present in the meeting and there are no independent witnesses. We acknowledge Miss F’s experience of the meeting was not a positive one, and we do not doubt her account of how she felt at the time and afterwards.
52. We need to balance the evidence we receive fairly and consider all information available to ensure all our decisions are impartial and evidence based. We have received two differing versions of events from the meeting in September 2023.
53. We therefore are unable to favour one account over the other. We cannot reach a view based on the evidence available and we do not consider that any further investigation would shed any more light on this.
54. We are pleased to see the Trust has reflected on Miss F’s feedback about the meeting and has committed to make all complainants aware of their option to bring someone along for support in the future.
55. Following the meeting, the Trust wrote to Miss F and explained its clinical team had tried to make her aware that her clinical expectations could not be met and despite allocating a health care support worker, this had not reduced Miss F’s persistent contact with the urology service.
56. The Trust said because of this relationship breakdown, it had no choice but to discharge Miss F from the service. The Trust apologised for any distress this would cause and said it would inform Miss F’s GP and ensure she could be referred to another service in the area.
57. GMC Good medical practice on ending a professional relationship with a patient says:
‘in rare circumstances, the breakdown of trust between you and a patient means you cannot continue to provide them with good clinical care. This might occur when a patient has, for example, when a patient has persistently acted unreasonably.’
58. This guidance also sets out the responsibilities that organisations have when making this decision. It says organisations must:
• tell the patient or make arrangements for the patient to be told of the decision and the reasons for it – where practical, this should be done in writing • make sure arrangements are in place for the continuing care of the patient if they are unable to make arrangements for themselves • pass on all medical records without delay to ensure continuity of care • record the decision to end the relationship, making sure that information recorded in the patient’s records is factual and objective, and does not include anything that could unfairly prejudice the patient’s future treatment.
59. Based on the evidence we have seen, we consider the Trust reached the decision to discharge Miss F with a thorough consideration of any other options available that would provide support to Miss F.
60. The Trust had attempted to agree a communication plan with Miss F to allow her to receive a consistency of care and the urology service could continue to take overall responsibility. Despite this, Miss F’s level of contact continued, and The Trust discharged her from its service.
61. We consider the Trust followed relevant guidelines when making this decision and communicating this to Miss F and we have seen no indications the Trust have done anything wrong.
Conclusion
62. We understand Miss F has felt distress and anxiety from her experiences with the urology service at the Trust. We hope our investigation will provide reassurance the Trust’s actions were in line with standards and guidelines.