13. 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 something has gone wrong.
Hernia repair
14. Mrs F says the Trust’s repair to her mother’s hernia in September 2023 blocked Mrs J’s stoma. Mrs F suspects the operation affected her mother's mesentery which moved the tumours and caused the blockage. The mesentery is a piece of connective tissue within the abdomen.
15. Mrs J’s stoma output after the operation was smelly and watery. Mrs F feels this demonstrated the stoma was blocked. She says her mother’s continuing abdominal pain shows it was blocked too.
16. The Trust's complaint response reassured Mrs F her mother's mesentery was in the same position before and after the operation. It said the fact stoma output continued throughout her mother’s time in hospital indicated it was not blocked. It added CT scans showed no indications of obstruction after the hernia repair.
17. EHS guidelines set out the type of repair the surgeon should have done. It says if a patient has an emergency obstructed bowel then the surgeon should avoid using mesh due to the risk of an infection.
18. Mrs J needed the hernia repair immediately so the Trust performed the operation as an emergency. The surgeon identified the hernia visibly contained part of Mrs J’s small bowel. They then repaired the hernia and sealed the wound but chose not to use mesh.
19. Our adviser explained there are no specific guidelines on how a hernia repair should be done, but the surgeon performed the operation in a standard fashion. Our adviser said based on Mrs J’s medical records there are no indications of complications. There is no indication the surgeon moved Mrs J’s mesentery, disturbed any tumours or caused a blockage.
20. Having looked at what happened we are satisfied the Trust repaired Mrs J’s hernia in line with relevant standards.
21. We recognise the distress this has caused Mrs F and understand the worry this has caused her. We hope the explanation above can put this distress to rest.
Input from The Christie
22. Mrs J feels the Trust should have spoken to The Christie to understand her mother’s cancer before performing the hernia repair.
23. The Trust has explained to us that Mrs F was under the care of oncologists at The Christie. It said these are experts in providing cancer care, but they are not surgically trained. With this in mind, they would have no role in advising on a hernia repair.
24. GMC guidance says doctors must work collaboratively with colleagues. In doing so, they should respect and refer to the skills and contributions of others.
25. The Trust’s surgeon did not contact The Christie directly to discuss the hernia repair. However, they knew Mrs F had a neuroendocrine cancer and The Christie was providing care for this problem.
26. Throughout Mrs J’s admission the Trust liaised directly with a liver surgeon at Manchester Royal Infirmary. They advised to repair Mrs J’s hernia through a small incision, but if this was not possible then the surgeon at the Trust should make a large incision and remove her gallbladder at the same time.
27. Our adviser explained staff at the Trust did communicate with relevant specialisms at other hospitals.
28. The surgeon who performed the hernia repair did not speak to cancer specialist colleagues at The Christie. We do not believe it was necessary for them to do so due to the type of operation Mrs F needed. Furthermore, the Trust did get relevant input from the surgeon at Manchester Royal Infirmary who was able to give relevant advice.
29. We therefore consider staff at the Trust collaborated and communicated in line with guidance prior to operating on Mrs F.
30. We acknowledge the heartbreak Mrs F’s death has caused Mrs J. We understand how her concerns about the surgeon’s collaboration have only added to this upset.
Blockage investigation
31. Mrs F complains the Trust did not investigate her mother’s blocked bowel using a GA-68 PET scan as it should have done. This is a technique to identify where neuroendocrine tumours are in someone’s body.
32. EHS guidelines say the preferred imaging technique to diagnose a bowel obstruction is with a CT scan. This is because a CT scan can provide important information about the cause and location of the obstruction.
33. The Trust did not give Mrs J a PET scan. However, The Christie did a CT scan of Mrs J’s abdomen and pelvis on 4 September. This identified part of her bowel was stuck in a parastomal hernia. It appeared this was restricting blood flow to the bowel and so the surgeon at the Trust decided she needed emergency surgery.
34. Our adviser explained patients with neuroendocrine tumours would have a PET scan to understand how the disease has spread throughout their body. A PET scan would not have produced images of Mrs J’s abdomen and pelvis, where her parastomal hernia was.
35. They said a GA-68 PET scan would not have changed the surgeon’s decision that Mrs J needed an operation to repair he parastomal hernia. Likewise, a PET scan would not have provided any additional information that would have improved how the surgeon performed the operation.
36. We consider there was no reason to give Mrs J a PET scan. The CT scan from three days before the operation provided the surgeon with all the information they needed when deciding if and how to perform the operation.
Pain management
37. Mrs F says her mother was in 'excruciating pain' on the ward whilst recovering from her operation. She feels staff at the Trust did not properly manage this pain.
38. BPS guidance recommends doctors manage someone’s pain based on their individual needs. They should aim to optimise pain relief while minimising negative side-effects. It says opioids are the primary way to manage pain, but come with unwelcome consequences like constipation and nausea. Therefore, alternatives should be explored.
39. NICE guidance says doctors should immediately relieve pain using a strong opioid. Staff should then seek advice from a palliative care specialist to understand the cause of pain and decide future management.
40. Notes show Mrs F experienced periods where she had uncontrolled pain during the day and night. Staff monitored this regularly, and contacted the Trust’s specialist pain team and palliative care team when the pain became unmanageable.
41. Staff were giving Mrs F painkillers throughout this period and continued to review how effective they were. When the painkillers were no longer working they gave her strong opioids to help control the pain she was in.
42. Our adviser explained managing a patient’s pain is not always straightforward - especially with a progressive illness like Mrs J’s cancer. This is because the underlying cause is always present and cannot be cured. Consequently, treatment focused on reducing the symptoms and managing her associated pain.
43. We can see Mrs F did experience pain during the final stages of her life. We understand how distressing this was for Mrs J to witness. We also know staff got relevant specialist input to manage this. Staff followed this advice and managed Mrs F’s pain by providing appropriate drugs. They gave stronger medication when these did not work.
44. We consider staff followed relevant guidelines when trying to manage Mrs J’s pain. We recognise Mrs J experienced excruciating pain despite the Trust’s efforts. We understand how this made the heartbreak of her mother’s death even more upsetting for Mrs F. We recognise how distressing this experience has been.