Symptoms following Surgery
22. Ms A said U was struggling to eat following the ENT surgery due to her being in pain and being unable to swallow. Ms A said the Trust forced U to have a bite of toast despite her being in pain. Ms A said U was discharged despite struggling to eat and the Trust should have realised something was wrong. Ms A said the Trust dismissed U’s symptoms following her surgery.
23. The Trust said U was appropriately reviewed by the anaesthetist and surgeon prior to her discharge and there were no concerns noted. The Trust said it also provided safety netting advice to Ms A on what to do if U’s condition worsened. The Trust said the nursing team encourage young people to eat and drink following the procedure and it is an important part of their recovery.
24. The RCS guidance says surgeons should provide patients with satisfactory postoperative care. Our ENT adviser explained there is usually a three-hour observation period after the operation, with a view to discharging the patient if there are no complications during that time. If there is poorly controlled pain or poor oral intake at three hours, our adviser said the patient should be observed for a further period of up to three hours and then may be discharged.
25. From the records we can see the Trust completed U’s surgery and she was taken to recovery at approximately 3.55pm. We can see U stated she was in pain and the Trust prescribed pain relief.
26. Approximately 90 minutes later we can see a nurse asked for a review of U due to her complaining of a tight chest and that she was unable to swallow. We can see the Trust reviewed U and noted her chest was clear, and her throat looked well with no adhesions.
27. We can see approximately 35 minutes later U advised that she was unable to swallow and she was reviewed by the surgeon. The surgeon documented they assessed U, including looking at her throat and noted they had no concerns and pain relief was provided.
28. One hour later, the Trust documented U had consumed juice and toast. It noted she reported feeling much better, and she was able to swallow easily. The Trust commenced discharge and provided safety netting advice to Ms A on what to do if U became unwell.
29. Our ENT adviser said it is better for children to recover at home as they are more comfortable. They explained that as U was able to eat and drink following surgery there was no reason for her to be kept in hospital and she was able to be discharged.
30. From the evidence we have seen, we have found the Trust has acted in line with RCS guidance, and we have found it did not dismiss U’s symptoms. It appears the Trust did take U’s symptoms seriously as she was reviewed within approximately 30 minutes on both occasions she reported being unable to swallow.
31. We can see the Trust reviewed U and examined the surgical site noting it looked good and there were no concerns. This is in line with RCS guidance which says surgeons should provide satisfactory postoperative care.
32. We understand Ms A is concerned that the Trust did not realise something was wrong as U was struggling to eat and swallow. We can see prior to her discharge, although U was initially in some discomfort, the Trust noted U reported feeling better and her swallow had improved.
33. For this reason, we would not be able to say the Trust missed something was wrong, as on her discharge, the reported issues appear to have been resolved.
34. We have found the Trust has acted in line with RCS guidance as it reviewed U prior to her discharge and noted she was feeling better, she was able to eat, and she was able to swallow. This is in line with RCS guidance which says surgeons should provide satisfactory postoperative care.
35. We recognise Ms A may be disappointed by our decision, especially as she has told us she believes this impacted on U’s health and caused her to be admitted to hospital. We acknowledge how worrying this has been for Ms A. We hope our decision provides reassurance to both U and Ms A that the Trust did act on and take their concerns seriously.
Pain Relief
36. Ms A said following U’s turbinoplasty in early December, the Trust discharged her with a seven-day supply of liquid ibuprofen and liquid paracetamol. Ms A said the Trust did not provide stomach lining tablets to take alongside the ibuprofen and this caused U to develop gastritis. Gastritis is when the lining of the stomach becomes inflamed and it can cause pain, indigestion and feeling sick.
37. The Trust said paracetamol and ibuprofen are commonly prescribed pain relief following a turbinoplasty and it does not usually provide medication to protect the stomach lining of children. The Trust said U’s gastritis could have been caused by taking ibuprofen on an empty stomach.
38. BNF says children aged between 12 and 17 years can be provided up to 400 mg of ibuprofen, four times a day. It also says children aged between 12 and 15 years can be provided between up to 750 mg of paracetamol, every four to six hours, four times a day. Our ENT adviser said there was no guidance which stipulates stomach lining tablets should be provided alongside analgesic to children.
39. From the records we can see the Trust discharged U with liquid paracetamol and liquid ibuprofen. The Trust prescribed U 400ml of liquid paracetamol to be taken every four to six hours as needed. We can see this was in line with the BNF guidance above. The Trust also prescribed U 400ml of liquid ibuprofen to be taken every six to eight hours as needed. We can see the Trust prescribed both analgesics in line with the BNF guidance.
40. Our ENT adviser explained a protective agent for the stomach may be prescribed if the patient is taking anti-inflammatory medication for a long time. In this case we can see the Trust prescribed U a seven-day supply of pain relief and our ENT adviser told us this would be a short-term usage and stomach lining tablets would not have been required.
41. We have found no failings in the Trust prescribing pain relief to U without providing stomach lining tablets. This is because we can see the Trust acted in line with BNF guidance in the pain relief it prescribed to U.
42. We understand Ms A will be disappointed by our decision, particularly as she is concerned the Trust not providing stomach lining tablets caused U to develop gastritis. We acknowledge how difficult having this has been for U. We hope our decision clearly explains why there is no failing in the Trust not providing stomach lining tablets following U’s surgery.
Diagnosis, Investigations and POTS
43. Ms A said the Trust kept U in hospital for over three months with no plan of action. Ms A said the Trust refused to perform an endoscopy which she believed was a needed investigation into U’s abdominal pain.
44. Ms A said this put a massive pressure on her mental health as she did not know what was wrong with U and this was very worrying for her. She said it also had a financial impact as she was unable to work whilst U was in hospital. Ms A said this also caused U to feel lost and she would cry for hours.
45. The Trust said it understood Ms A felt U required certain investigations, but these were not clinically indicated. The Trust said it had explained the plan of care for U to Ms A and explained why certain investigations were not being requested.
46. GMC guidance says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary. Our adviser explained an endoscopy provides limited and specific information, and it is only really helpful for looking at the lining of the bowel. They said it is advised in much older patients to exclude malignancy.
47. We can see U was admitted to the Trust for approximately three months and we have reviewed U’s medical records for this period. For the purpose of this report, we have used a selection of entries from the medical records to evidence our consideration of this part of the complaint. This is by no means an exhaustive list, and does not include each review, assessment, consultation that was completed, or each test and investigation that was requested.
48. From the records we can see the Trust admitted U in mid-January and she was reviewed by the gastro team alongside the dietitian to form a plan of care. We can see the dietitian reviewed U and advised her to have frequent sips for hydration and they noted Ms A advised U was not able to sip anything, and U confirmed this.
49. The dietitian prescribed oral supplements to U for nutrition. We can see in the days following this Ms A had informed staff U was not able to tolerate any oral intake, and she was commenced on an NG feed.
50. We can see the Trust completed a barium swallow test which is an X-ray used to examine the upper digestive area. This test showed normal motility, which means there was no delay to gastric emptying, and no evidence of reflux disease. We can see the Trust also performed blood tests and performed an abdominal ultrasound and the results were normal.
51. We can see the Trust discussed with Ms A whether there was a psychological aspect to U’s condition and it referred them to the psychology department for review. We can see the psychology team spoke with U and Ms A and they declined support at that time. We can see Ms A requested an endoscopy and for a gastro consultant to review U and the medical team explained these were not necessary interventions at that time.
52. We can see towards the end of January, the dietitian advised that they could start to ween U off the NG feed and start oral supplements. They noted Ms A was happy with this plan. The Trust noted to encourage U to eat small amounts little and often to improve her oral intake.
53. The Trust noted it discussed with Ms A that it was unclear from a medical standpoint why U was unable to eat and that there may be a psychological reason for U’s illness. The Trust referred U to the psychology team with Ms A’s agreement.
54. We can see during this time the Trust also reported Ms A was closing the curtains surrounding U’s hospital bed. The Trust noted she had been told by staff to keep them open so they could witness U’s vomiting and any oral intake.
55. We can see in late January the Trust had a working diagnosis of functional brain gut disorder and had requested a second opinion from the gastro consultant. We can see in early February the Trust noted it felt U’s illness was functional and it explained this to Ms A and that U had no underlying gastro-intestinal issues. We can see U had reported she hadn’t opened her bowels for ten days and the Trust arranged an abdominal X-ray and provided laxatives.
56. U had a day’s home leave, and on her return the Trust noted she reported she had vomited and had experienced loose stools. This resolved on her return to the ward. In mid-February we can see there was a discussion between Ms A, the gastro-intestinal team and the paediatric consultant. We can see they advised Ms A an endoscopy was not indicated at this time.
57. We can see the Trust explained the tests and investigations it had conducted so far had all been normal and they had ruled out most gastro-intestinal diseases. We can see Ms A expressed she was unhappy as U did not have a diagnosis and the Trust advised she had a working diagnosis of functional brain gut disorder. They explained they felt an endoscopy would also provide a ‘normal’ result and therefore was unnecessary.
58. We can see in mid to late February the Trust obtained a second opinion by a paediatric gastroenterologist consultant, and they recommended an endoscopy. They reported it was likely to be normal, but they felt this test was important to reassure U and Ms A that there was not a gastric reason for her illness that had been missed. They also documented they felt it was highly likely this was a functional disorder that would remain medically unexplained.
59. We can see throughout this time U reported vomiting after each NG feed. The Trust noted her weight had increased and was now within the correct range for her height.
60. In early March we can see U requested having her NG tube removed as she wanted to try and start eating and drinking again. The Trust arranged for this to be removed and it prescribed oral supplements for nutrition.
61. We can see U was reviewed by an ENT surgeon who noted there was some slight nasal obstruction on the left side and slight swelling on the right but with good airflow on each side. The ENT surgeon prescribed a nasal spray and noted they did not need to see her again.
62. We can see the dietitian reviewed U a few days later and she reported she had not eaten since the NG feed was removed, and this was re-commenced by the Trust. The Trust noted U had an endoscopy booked in mid to late March. It noted the results were normal and it discussed discharge with Ms A and she requested for U to remain as an inpatient.
63. In mid-April we can see the Trust requested a second opinion from a gastro consultant at a second trust at Ms A’s request.
64. We can see the Trust held an MDT meeting and noted gastroenterology were no longer involved as all the investigations were normal. We can see the Trust discussed gastroparesis and it was felt by the professionals at the Trust that there were no further investigations required as it had already ruled out upper GI conditions. We can see the Trust documented it planned to discharge U as long as her weight and oral intake was able to be maintained and managed in an outpatient setting with weekly appointments.
65. We can see in late April the Trust documented U’s weight had increased and she was able to tolerate a higher oral intake of food. The Trust discharged U at the end of April.
66. Our adviser said U’s symptoms were not in keeping with any described organic disease. They explained the challenge for the Trust would be to try and control her symptoms, returning her to normal function without undertaking unnecessary investigations that carry their own risks. Our adviser confirmed the Trust acted appropriately in the tests, investigations and care it provided.
67. From the evidence we have seen, we have found the Trust has acted in line with GMC guidance. We can see the Trust provided a working diagnosis of brain gut disorder approximately two weeks after U was admitted. The diagnosis was based on U’s presenting symptoms after other conditions had been excluded.
68. We have also seen U was reviewed weekly by the dietitian and her plan of care was updated each time. The Trust also completed daily ward rounds with the medical team, and we have seen U was also regularly reviewed by the lead paediatric consultant with input from the gastro team.
69. We can see the Trust completed many investigations such as a barium swallow test, ultrasound, endoscopy and blood tests. We can also see the Trust was reluctant to perform investigations, such as the endoscopy, which were unlikely to provide much benefit. We can see the Trust kept Ms A informed regarding the investigations it was undertaking and the reasoning for each of these, including where it did not think further investigation would be useful.
70. We acknowledge how worrying this period was for Ms A, and how concerned she was about not understanding what was wrong with U. We have found the Trust has acted in line with GMC guidance which says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary, which we can see the Trust did.
71. We will next consider whether the Trust missed a diagnosis of POTS. Ms A said the Trust missed a working diagnosis of postural tachycardia syndrome (POTS) by not investigating her high blood pressure.
72. Our adviser explained there are no UK guidelines for diagnosing POTS. We have looked at the Canadian Cardiovascular Society guidance which lists the following criteria as needing to be present for over three months. The criteria includes: light-headedness, palpitations, headaches, chest discomfort, frequent nausea and abdominal pain.
73. It also says the criteria for POTS requires children under 19 years to sustain a high heart rate (an added 40bpm from what is normal for the patient). It says patients must go from lying to standing and sustain this heart rate for 10 minutes with no significant drops in blood pressure.
74. We can see the specialist nurse reviewed U following her diagnosis of POTS in 2024. They noted they explained to Ms A that POTS is diagnosed in the absence of low blood pressure. This means if a person’s blood pressure drops on standing, this would not be considered POTS.
75. We have found the Trust did not miss a diagnosis of POTS during U’s admittance. We have not seen any evidence that U was displaying all the criteria needed as listed above.
76. We can see U regularly reported nausea and abdominal pains, but we have not seen any evidence that U had been experiencing light-headedness, palpitations, headaches or chest discomfort for over three months whilst an impatient. Our adviser confirmed U was not displaying symptoms that would have indicated further investigations into POTS was needed.
77. We can see whilst admitted there were instances of U having high blood pressure whilst she was an inpatient, but this was in isolation and would lower itself over time. The Trust did not conduct sitting and standing blood pressure tests during U’s admittance, so we are not able to say whether U had a raised blood pressure on standing and if this was sustained for ten minutes.
78. As explained above, U did not meet the criteria for POTS, so we are not able to say it is a failing that the Trust did not conduct the lying and standing tests as these were not indicated. We have found the Trust acted in line with the Canadian guidance which says all symptoms must be present for over three months.
79. We can see in September U reported to her GP Practice that she was experiencing chest pains and feeling dizzy with her heart racing on standing. U also reported having a headache for a few days. We can see the GP checked U’s blood pressure on standing and referred her to the Trust as it queried POTS. U was seen by a second trust as the Trust does not offer tests for POTS, and this was diagnosed later that year.
80. In summary, we have found no failings in the tests and investigations conducted by the Trust. Our adviser confirmed the Trust undertook appropriate investigations at relevant stages. We understand Ms A thinks some of these investigations should have happened sooner, and we hope she is reassured these were undertaken only when necessary.
81. We have also found no failings in the Trust not providing a diagnosis to U. We acknowledge Ms A continued to experience worry about what was wrong with U throughout the admission. We can see she received a diagnosis of brain gut disorder within two weeks of her admittance.
82. Lastly, we have seen no evidence the Trust missed a diagnosis of POTS as it appears U’s symptoms for this were not present whilst on the ward. We understand why Ms A is concerned this was missed, given U had some of the symptoms of this while at the Trust, and was later diagnosed with POTS.
83. We understand Ms A will not agree with our decision, and we are very sorry for any distress this may cause.
Safeguarding Concerns
84. Ms A said the Trust made false allegations against her in a report it made to social services. She said the Trust documented U was not being sick despite evidence that she was, including a signed document from staff members who confirmed they had seen U be sick.
85. Ms A also said the Trust documented concerns that U was making herself sick. Ms A said she felt attacked, bullied and the Trust blamed her mental health for U’s illness. Ms A said this was very stressful for her and has impacted her physical and mental health.
86. The Trust said the safeguarding referral was made due to concerns relating to Ms A’s behaviour and interactions on the ward. The Trust said it used information from U’s medical records and from conversations with staff and Ms A when making the safeguarding referral. It apologised for the upset and distress this referral caused to Ms A.
87. The safeguarding children guidance says practitioners should be proactive in sharing information as early as possible to help identify, assess, and respond to risks or concerns about the safety and welfare of children. It also says practitioners should be alert, to sharing important information about any adults with whom that child has contact, which may impact the child’s safety or welfare.
88. We have reviewed the safeguarding (SG) referral the Trust raised in mid-February 2023. We would like to make it clear this is not an exhaustive list, and we have focused on the information within the referral that Ms A has told us was incorrect.
89. In the SG referral the Trust documented it had concerns Ms A was reporting U was unable to eat and she was suffering with pains. The Trust noted there was no evidence of a medical condition that would cause this, and she was receiving psychological support. The Trust reported its concerns that U’s illness may have been exaggerated or overly reported, possibly due to Ms A’s mental health.
90. From the medical records we can see there are numerous instances within the records where it is recorded U reported being in a high level of pain, between 7 and 10 out of 10.
The Trust has also noted that whilst U was reporting being in a high level of pain, there was no evidence in her presentation that she was in pain, and she also declined pain relief.
91. We have also seen numerous references within the records where Ms A declined food for U, and informed staff U would not be able to eat as she would be sick.
92. We can see a few days after the Trust admitted U, it referred both her and Ms A for psychological support, with Ms A’s agreement. We can see the psychology team visited Ms A and U on the ward together the following day and following discussion, Ms A declined psychological input.
93. We can see the Trust referred U to psychology again, with Ms A’s consent, a few days later due to concerns her illness was psychological and not medical.
94. In the SG referral the Trust reported Ms A told staff U would not eat, despite U agreeing to try, and that Ms A was not following medical advice. The Trust said Ms A reported instances where U had been sick and had not opened her bowels, despite there being no evidence of this.
95. From the records we can see the Trust had completed a vomit chart which clearly indicated when U had been sick, and whether this was witnessed by staff. Ms A has also provided us a signed document with staff that had witnessed U being sick.
96. We have also seen the Trust documented U reported not opening her bowels for 10 days, and this was not supported by the subsequent X-ray.
97. The Trust documented within the referral that Ms A was aggressive on the ward. It said if she did not agree with the plan of care, she would attempt to control staff and had displayed obsessive behaviour.
98. We can see in early January the Trust had admitted to U for a medical assessment due to repeat attendances. We can see following this assessment, the medical team attempted to discharge U home, and they documented Ms A was refusing to go home.
99. We can see the Trust admitted U in mid-January. A few days later, it documented Ms A was displaying strange behaviour towards staff, such as filming staff, making threats and shouting at staff. We can see the Trust spoke with Ms A regarding the aggressive behaviour it felt she was displaying to staff and it explained what would happen if this continued.
100. We can see the Trust also documented concerns that Ms A would not leave U alone. It also documented Ms A would stay on the ward whilst U was at school, despite being asked to leave by staff.
101. We can see the Trust also documented Ms A was pushing for medical tests that doctors did not feel were necessary. It noted it informed her that only clinically indicated investigations would be undertaken. It reported all the investigations it had undertaken were normal and there was no medical cause for U’s difficulties.
102. Our nurse adviser confirmed that based on the concerns the Trust had noted and which were shared by multiple members of staff regarding Ms A and U, it was appropriate to document these concerns and raise a safeguarding referral.
103. From the evidence we have seen, we have found the Trust has acted in line with the safeguarding children guidance. We can see the Trust clearly documented it’s concerns within the medical records as events occurred.
104. Based on the concerns noted by staff involved in U’s care the Trust raised a safeguarding referral. We have found this is in line with the safeguarding children guidance which says practitioners should be alert, to sharing important information about any adults which may impact the child’s safety or welfare.
105. We recognise Ms A has told us the allegations within the report are false. We acknowledge how difficult it must have been for Ms A when the safeguarding referral was made. We understand Ms A does not agree with the Trust’s account.
106. We have reviewed U’s medical records, and we have found evidence within the records that supports the concerns noted by the Trust within the referral. This makes it very difficult for us to say the information in the report is inaccurate. This is because we can see the Trust has used contemporaneous notes from throughout U’s records and time in hospital in the referral it made.
107. We understand Ms A will be very disappointed in our decision. Ms A told us the Trust referring her to social services made her feel vulnerable, threatened and was deeply upsetting for her. We do not want our decision to diminish the impact Ms A told us this had on both her and U. We recognise how difficult and upsetting this was for them both.
Gastric-Emptying Test and Gastroparesis
108. Ms A said a second Trust completed a gastric emptying test in February 2025 which confirmed U had mild gastroparesis. Ms A said since April 2023 the Trust refused to perform a gastric emptying test and therefore missed a diagnosis of gastroparesis.
109. The Trust said it performed a GI contrast study, and its findings were normal. The Trust said as its investigations had shown prompt gastric emptying, it felt significant delayed gastric emptying was unlikely and therefore further tests were not necessary.
110. The BSG guidance says gastric emptying testing should not be undertaken routinely in patients with typical symptoms of functional dyspepsia (FD). FD is used to describe gastrointestinal symptoms that do not appear to have any clear cause.
111. The BSG guidance also explains gastric emptying test results have not been demonstrated to predict treatment response consistently. This means there is no consistent link between gastric-emptying tests and effective treatment being provided following this.
112. Please see paragraphs 48 to 65 where we have detailed the tests, investigations and diagnoses documented by the Trust.
113. From the records we can see in mid-January, a few days after the Trust had admitted U, Ms A asked staff whether U could have gastroparesis. The Trust documented it informed Ms A that U may not have a specific diagnosis and it had requested a barium swallow test.
114. We can see the Trust completed the barium swallow test which showed there was no delay to U’s gastric emptying. We can see the Trust discussed these results with Ms A and advised gastroparesis is a rare condition and it needed to rule out the more common conditions it could be first.
115. We can see Ms A and U attended a second trust for a second opinion with a gastro consultant in April 2023. We can see the consultant documented there may be some degree of gastroparesis and recommended a gastric emptying test. They also noted there is a pathway between the brain and the gut (brain gut disorder) which can cause abdominal pain, nausea, vomiting, constipation or diarrhoea and this is more common than gastroparesis.
116. At the end of April, we can see the Trust discussed the consultant’s second opinion with Ms A. We can see the Trust advised it had ruled out an upper GI problem and throughout its investigations, it had not seen any evidence of gastroparesis. The Trust confirmed there were no signs of gastroparesis on the barium swallow test and it explained U would need to return to the second trust for the recommended test.
117. From the evidence we have seen, we have found the Trust has acted in line with BSG guidance. We can see the Trust had diagnosed U with brain gut disorder which is a functional illness. We have found the Trust has acted in line with the BSG guidance which says gastric emptying tests should not be undertaken in patients with typical symptoms of FD, which in this case U had.
118. Our adviser confirmed the diagnosis of brain gut disorder was appropriate and as the barium swallow test results were normal, a gastric emptying test was not indicated. As the gastric emptying test was not clinically indicated we are not able to say the Trust missed a diagnosis of gastroparesis. We have found the Trust acted in line with the relevant guidance in the tests it conducted and did not miss a diagnosis of gastroparesis.
119. We recognise Ms A is concerned the Trust should have performed this procedure, ad we understand this concern given U later received a diagnosis of mild gastroparesis.
We acknowledge the impact this has had on both U and Ms A.
120. We acknowledge this was an incredibly difficult time for both U and Ms A, and our decision is in no way meant to detract from that. We are likely to not uphold Ms A’s complaint