University Hospitals Coventry and Warwickshire NHS Trust

4.Mr E complains about the treatment he received from the Trust between March 2023 and May 2025, in relation to a skin disease requiring surgery. Specifically, Mr E complains:

• his first surgery on 8 March 2023 was not completed appropriately, too much tissue was removed, and wound did not lie on the midline of the cleft as it should have – he says this contributed to his ongoing issues with wound healing • appropriate action was not taken during the follow up appointments on 18 May 2024 and 29 February 2024, to address the poor wound healing • the second surgery on 28 August 2024 did not resolve the earlier issues, but instead worsened the unhealing wound • appropriate action was not taken during the follow up appointments on 9 October 2024 and 4 December 2024, to address the worsened wound • there was a delay in referring him to plastic surgery; Mr E says this should have occurred after the first failed surgery or when he requested this on 16 September 2024 • the Trust’s refused to hold a face-to-face meeting or engage in mediation for the issues during its complaint handling.

4. As a result of the above failings, Mr E says he has experienced an extended period of ill health and has needed further surgeries.

5. He says his failed recovery has had a significant impact on his physical and mental health. He feels this could have been resolved sooner had the Trust referred him for plastic surgery at an earlier time. He says an earlier referral would have meant he was further along on the 18 month waiting list for this.

6. Mr E says the Trust’s refusal to have a meeting or mediation has added to his distress at an already difficult time and has meant earlier opportunities to remedy his concerns were lost.

7. Mr E would like the Trust to reconsider his place on the waiting list for plastic surgery, in light of our consideration and any failings we may identify. Mr E is also seeking a financial remedy to recognise the impact of these events.

8. Mr E was diagnosed with a skin disease requiring surgery in December 2021. He was placed on the waiting list for surgery, and this took place in March 2023. Mr E feels that too much tissue was removed during this initial surgery, as three large pilonidal pit areas needed to be removed. Mr E feels this has caused ongoing concerns with wound healing, including bleeding, bad smell, and discomfort.

9. The Trust arranged a further surgery in August 2024 as Mr E’s wound had not healed. This surgery found a further area of recurrence of the disease.

10. Sadly, the second surgery did not fully resolve the wound concerns. Mr E’s surgeon referred Mr E onto a plastic surgeon who has relevant experience treating wounds and complex surgical disease in December 2024.

11. Mr E complained to the Trust in January 2025 and received its final complaint response in February 2025. He remained unhappy with the Trust’s response and felt more could have been done to meet with him and find a way forward to address the concerns, as he has been suffering and in pain for more than four years. He says these events have greatly affected his quality of life and impacted his mental health. Mr E therefore brought his complaint to us for further consideration in March 2025.

14. The law says we cannot investigate a complaint if there is, or was, a legal remedy that the aggrieved could or could have pursued, unless it is (or was) not reasonable to do so. In each case we consider whether a court could provide a complete remedy for the matter complained about and achieve the outcomes the complaint is seeking.

15. We have discussed this with Mr E to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed, but whether it would be a reasonable option to explore.

16. It appears there is a potential clinical negligence action open to Mr E, as he feels poor clinical care led to a worse outcome. Negligence, in law, is an act or failure to act (omission) that does not meet the level of appropriate care expected, resulting in injury or loss. If a doctor or health professional is negligent when giving medical treatment, this is called ‘clinical negligence’.

17. As a legal remedy appears to be open to Mr E, we then need to consider whether it is reasonable for him to pursue the matter in that way. In doing this, we have considered the outcomes Mr E is seeking, including the amount of compensation and whether we are likely to recommend it in relation to the injustice claimed. We discussed the figure Mr E is hoping to achieve by sharing our Severity of Injustice (SOI) scale with him.

18. Mr E confirmed he is seeking a large financial remedy and wanted to attempt to get legal advice believing the Trust’s actions amount to clinical negligence due to the physical harm it caused as a result of surgery.

19. Mr E is unsure what figure would be relevant to his complaint. He explained he has been left with ongoing life changing issues as a result of the surgeries and the failure of the wound management.

20. On 18 December 2025, Mr E advised us he had successfully sought legal advice, and his concerns will now be explored through the legal route.

21. We therefore consider it is reasonable that Mr E explore a potential legal route first, in line with our legislation, as this may provide a remedy for the key concerns Mr E raises and achieve the outcomes he is seeking.

22. We recognise Mr E is also seeking a reconsideration of his place on the plastic surgery waiting list. We consider this may be directly or indirectly a part of a successful legal claim, or this may provide a suitable alternative way forward for Mr E to have the treatment he needs. We therefore consider it is appropriate to wait for the conclusion of any legal advice or claim first, before considering this outcome.

23. If Mr E is unable to continue with his legal action he is welcome to return to us with any additional information about this so we can see if we can consider his complaint further.

24. Mr E can also return to us if, following legal action, he has outstanding outcomes that the court was unable to order, or if the court was unable to consider parts of his complaint.

25. We would ask that Mr E come back to us promptly if he is unable to proceed with legal action or if there are outstanding outcomes. This is because we are unable to investigate complaints brought to us more than 12 months after someone becomes aware of the problem. We can put this time limit to one side if we think there is a good reason to do so, and we would consider any legal advice or action sought.

26. Overall, we consider it is reasonable for Mr E to explore a potential legal claim. This is because Mr E has already taken some legal advice and intends to take legal action, and he has confirmed he has no barriers preventing him looking into this. We will therefore close Mr E’s complaint.

Conclusion

27. We are sorry to hear how distressing and painful this experience has been for Mr E. We hope he is able to gain the answers and outcomes he is seeking through the legal process. We hope our explanation reassures him about the next steps for seeking legal advice, and when he can come back to us if needed.

1. We have carefully considered Mr E’s complaint about the treatment he received from the University Hospitals Coventry and Warwickshire NHS Trust (the Trust). We were very sorry to hear about the treatment Mr E received after being diagnosed with a skin disease requiring surgery.

2. We understand this treatment and the time following must have been extremely stressful and worrying. In turn, we understand how difficult it was for Mr E to bring this complaint and discuss it with us. We are very grateful for his time and effort in bringing this complaint to our attention.

3. Mr E has advised us he wishes to attempt to obtain legal advice with a solicitor to consider his complaint against the Trust. We have therefore closed his complaint and will take no action on the complaint at this time. We have also explained the next steps if Mr E is not able to proceed with a legal claim, or if there are outstanding outcomes or parts of the complaint which the courts were not able to consider.