5. Mr F complains the Trust failed to advise him of the risks of the penile straightening surgery he had in early January 2023.
6. Mr F says as result of the operation his penis is three centimetres shorter than preoperatively. He says the circumcision has also left him unable to climax during sexual intercourse which has had both a physical and emotional impact on both him and his partner. He wants an apology, service improvements and a financial remedy.
7. Mr F received a diagnosis of Peyronie's disease in 2021 and underwent corrective surgery in early January 2023.
11. Mr F complains the Trust failed to advise him of the risks of the penile straightening surgery he had on 9 January 2023 as treatment for Peyronie’s disease. He told us that during the consultation to discuss the surgery, the Trust discussed the side effects and told him, the change to the length of his penis after surgery would be insignificant and it would not cause any problems. He told us the Trust advised him that circumcision (surgical removal of the foreskin) would ease the tightness at the end of his penis but did not tell him about the significant loss of sensitivity that would result from the circumcision.
12. GMC guidance on decision making and consent say:
• ‘All patients have the right to be involved in decisions about their treatment and care and receive support to make informed decisions if they are able.
• Decision making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.
• All patients have the right to be listened to, and to receive the information they need to decide and the time and support they need to understand it.
• Medical professionals must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.’
13. The Trust saw Mr F in late October 2022 to discuss surgery to correct the curvature of his penis.
14. Our clinical adviser has explained there are two different surgical procedures for Peyronie’s disease which are penile plication, or plaque excision. Penile plication causes penile shortening and plaque excision causes less shortening, but there is a higher risk of erectile failure. They go on to say this information is available for patients with Peyronie’s disease that are contemplating surgery in a document called Peyronie’s disease Information about your penile condition published by The British Association of Urological Surgeons (BAUS).
15. During the consultation, the doctor discussed the penile plication procedure only with Mr F. During this discussion the Trust told him the risks of surgery including that of the circumcision. The complications following surgery discussed included swelling, bruising, pain and loss of compromised sensation. We have found that during the discussion about the loss to the length of his penis after surgery, the doctor noted in the records they told him this is ‘usually not really significant’.
16. Therefore, we consider that although the Trust had long conversations with Mr F pre- surgery, and did discuss some risks with him, it did not act in line with guidance in how it communicated these risks with him using language that underestimated the physical impact post-surgery.
17. It also did not act in line with GMC guidance in that it did not discuss other types of procedures with Mr F or its rationale for the procedure it offered him. We consider a discussion on other options for treatment alongside the provision of the information guide for patients with Peyronie’s disease would have allowed Mr F to make a more informed decision about his treatment and the potential risks post-surgery.
18. We have gone on to look at the discussion the Trust had with Mr F around the circumcision. We can see the doctor noted in the records they explained to Mr F that they would carry out this procedure at the same time as the surgery to correct the curvature to his penis as it would help with the tightness he was experiencing with his foreskin when he had an erection. As explained earlier, during this discussion the Trust explained the complications following surgery which included compromised sensation. It is not clear in the records, if this risk was specific to the circumcision or for the surgery alone.
19. We therefore consider the Trust did not fully act in line with GMC guidance in its communication with Mr F during the discussions about his penile correction surgery and circumcision. We cannot see it provided him with the information he needed to make a fully informed decision about his treatment. It also appears the Trust was not clear in the detail it gave Mr F about the risks of his surgery in relation to the penile curvature correction and circumcision in that the wording it used during these discussions minimised these risks.
20. As we have identified a failing, we have gone on to look at the impact this had on him.
21. Mr F says result of the operation his penis is shorter than preoperatively. He says the circumcision has also left him unable to climax during sexual intercourse which he told us has had a physical and emotional impact on both him and his lifelong partner. He told us how this was an important part of their sexual relationship and how distressing and upsetting it is as he fears this is something he will never have again. He told us that psychologically he feels like he has lost a limb.
22. Due to the nature of the complaint, we sought impact advice. Our clinical adviser explained Peyronie’s disease is a disabling condition which interferes with sexual function which if untreated can lead to a range of complications including painful sex and erectile disfunction. They go on to say all procedures available to treat the disease carry their own risk and a perfect outcome is unlikely.
23. We cannot say that the Trust not fully and clearly discussing the two options available or the failing we have identified in its communication with Mr F during the discussion pre-surgery has led to the impact he has told us about in relation to his ongoing sexual relationship with his lifelong partner and his inability to climax. It is important to note, Mr F was experiencing difficulties with erectile disfunction before surgery which he was on mediation for. He has told us his main priority for surgery was in relation to the curve in his penis.
24. We do consider a more detailed and realistic discussion about the nature and treatments of his disease would have allowed him to make a more fully informed decision on his treatment.
25. We also consider that clearer communication in the discussions the Trust’s did have with Mr F may have prevented some of the distress he has suffered since his surgery due to the more significant change in the length of his penis than he thought might be the case. It is clear from what he has told us, the surgery and circumcision have had an impact on his physical and emotional relationship with his partner which he does not seem to have been fully aware of as a risk.
26. We accept that we do not know what treatment option Mr F would have chosen had the Trust discussed all treatment options with him, but we consider he would have known that complications following surgery were a possibility and could be as significant as they now are for him. However, we do consider it could have managed his expectations better.
27. Although in its final response the Trust has apologised for the upset the experience has caused Mr F, it has not recognised the distress he continues to experience and the impact this has had.
1. Mr F is understandably concerned that St George’s University Hospitals NHS Trust (the Trust) did not discuss the risks of the penile straightening surgery he had in early January 2023.
2. We were sorry to hear about what happened and how he continues to feel the effect on both his mental and physical wellbeing post-surgery and how this has impacted his relationship with his long-term partner.
3. After carefully considering all the evidence we have found that although the Trust did have several discussions with Mr F before his procedure and did discuss some risks with him, it did not act in line with guidance in how it communicated these risks. We also consider it did not fully explore all options for treatment with him or provide the information necessary for him to make an informed decision.
4. We therefore consider the identified failings to have led to some of the impact Mr F has described. From what he told us, he was not prepared for the physical impact he has experienced post-surgery which has caused him a great deal of distress as well as impacting his close relationship. We will partly uphold this complaint and make recommendations at the end of this report.
28. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.
29. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
30. Our Principles for Remedy reflect the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
What we found 31. Through investigating Mr F’s complaint, we found:
• A failing in the management of its communication during its discussion with Mr F around the options for treatment and the risks of the procedures carried out.
What the Trust should do 32. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
33. The Trust should write to Mr F to:
• acknowledge the failings we found in its communication during its discussion with Mr F around the options for treatment and the risks of the procedures carried out. We also recommend the Trust apologise for the impact it has had on Mr F • send a copy of this letter to us by 8 January 2026.
34. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.
35. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.
36. Following this review, we recommend the Trust:
• pay Mr F £750 in recognition of the impact the failing has had on him • send us evidence it has done this by 9 March 2026.
37. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure it does not repeat poor service.
38. We recommend the Trust:
• produces an action plan to address the failings found in this report relating to the its communication during its discussion with Mr F around the options for treatment and the risks of the procedures carried out • identify the reason for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now). We ask that this includes action to improve the patient experience by giving information when there are treatment options to consider • for each action it should state who is/was responsible, timescale for completion, and how it will monitor compliance • share the action plan with us, Mr F, Care Quality Commission and NHS Improvement by 9 March 2026.