Trust A
The Law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason they could not complain earlier.
17. The following areas of complaint were made outside of our time limit:
• On 29 August 2023 Trust A wrongly diagnosed Mr N with constipation and failed to communicate appendicitis was a possible diagnosis.
• When Trust B identified Mr N’s appendix had burst on 30 August 2023 it failed to operate promptly
18. We have considered when Mr N had a reason to complain about both events. Mr N attended Trust A with stomach pain on 29 August 2023. Mr N was diagnosed with constipation. Mr N attended again on 30 August 2023, and he was diagnosed with an appendicitis that needed operating on. Mr N was given IVs and antibiotics, and the operation was delayed until 1 September 2023.
19. The dates of these events span 29 August to 1 September 2023. As the events happened close to each other, we have considered them both together.
20. Mr N was unhappy with the events at the time they occurred and had reason to complain about them by 1 September 2023 at the latest. To be in time, Mr N needed to bring these complaints to us by 1 September 2024.
21. Mr N brought these complaints to us on 14 February 2025, five months outside of our 12-month time limit.
22. Mr N complained to Trust A on 29 May 2024 approximately eight months after becoming aware he had reason to complain. Mrs N made this complaint on Mr N’s behalf.
23. Mrs N told us she and her husband appreciate the hard work of the NHS and believe doctors are human and can make mistakes. For this reason, they chose to forgive Trust A’s mistakes until they got to a breaking point on 16 April when Mr N’s hernia ruptured. Mrs N told us at this point they felt enough was enough and they had suitable reasons to complain.
24. Mrs N told us she asked the Trust several times how to complain which caused some delays. We can see in the email provided to us on 29 May, Mrs N stated she had been attempting to complain for the last three weeks.
25. We can see Mrs N had reason to complain from 1 September 2023. Mrs N waited eight months to complain to Trust A. We consider Mrs N had reason to complain earlier and did not need to wait until she got to breaking point. However, we can see she made Mr N’s complaint to Trust A within the timescale in NHS complaint guidelines. We consider this is reasonable.
26. Trust A responded to Mrs N’s complaint on 3 December, approximately six months after she submitted her complaint. This timeframe is keeping with NHS complaint guidelines. The response referred Mrs N to PHSO if she remained unhappy.
27. On 13 December, Mrs N sent a text message to Trust A stating she intended to take her complaint to PHSO. Mrs N brought her complaint to us on 14 February 2025, two months after she received the Trust’s response. We discussed this two-month delay with Mrs N.
28. Mrs N told us she did not come to PHSO in December because it was nearing Christmas, and she had to emotionally support her husband. Mrs N told us they do not live near family, and she was the only person that could support Mr N through this time.
29. Mr N experienced depression from before his hernia was identified in May 2024. Mrs N provided emotional support to Mr N during this time and was still able to complain to Trust A. We have not seen any evidence there was a change in circumstances in December 2024 that prevented Mrs N bringing Mr N’s complaint to us. For this reason, we are not persuaded this justifies the delay of two months between receiving the final reason and progressing the complaint to us.
30. We have decided there is not sufficient justification to put our time limit to one side to consider these parts of the complaint any further. We recognise this decision will be disappointing for Mr and Mrs N.
31. 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 we have not found any indications that something has gone wrong with the remaining elements of Mr N’s complaint about Trust A. We explain our reasons for this below.
Trust A did not insert a mesh when carrying out the laparoscopic appendicectomy on 1 September 2023
32. Mr N presented at Trust A with severe abdominal pain in the early hours of 30 August 2023. Mr N had a CT scan, and doctors diagnosed him with appendicitis. On 31 August, Trust A’s notes state it requested a laparoscopic appendicectomy and Mr N consented. Mr N had a laparoscopic appendicectomy on 1 September 2023.
33. A laparoscopy is a keyhole surgery where a small cut is made, and the operation is carried out using a camera. This avoids making a larger cut. The operation notes show the camera was inserted through a 12mm cut in Mr N’s belly button.
34. The operation found some dead tissue on the appendix, but the base was healthy. The appendix and 500ml of pus were removed and Mr N’s abdomen was washed out. The Trust placed a drain to allow further drainage of infection or pus. The notes record no complications or issues with the surgery.
35. On 15 April, Mr N was diagnosed with a para-umbilical hernia. This is when part of the intestine or stomach fat breaks through the muscles around it and causes a bulge by the belly button. A doctor who saw Mr N on this day told him the hernia had developed in the same place as the surgery. The doctor said a mesh was not put in place in the appendicectomy which caused the hernia to erupt.
36. When hernias are repaired, a synthetic patch of mesh will often be put in place to strengthen the muscle wall. Mr N had a history of hernias in this same place and had a previous hernia repair on 14 August 2018.
37. Mr N told us he complains about the surgery because Trust A went through the place of his original hernia and did not insert a mesh to prevent him developing a hernia.
38. RCS guidance advises when completing a keyhole surgery, the camera should be inserted through the belly button to access the abdominal cavity.
39. We can see Trust A acted in line with RCS guidance by inserting the camera through his belly button. We can see Mr N was concerned this was the wrong clinical decision as he had a history of hernias. We discussed this concern with our adviser, who reviewed Mr N’s records and his history. They explained the guidance was applicable to his care.
40. Considering the clinical advice and the guidance, we are satisfied Trust A acted correctly.
41. TSAC guidance says placing an artificial material like a mesh in an operation carries an increased risk of infection and of a hernia developing.
42. We can see Trust A did not insert a mesh during Mr N’s appendicitis operation. We consider according to TSAC guidance, inserting a mesh would have carried significant risk of infection and a hernia developing. Again, our adviser agreed this was appropriate in the individual circumstances of Mr N’s care.
43. Considering the evidence from our adviser and the guidance, we are satisfied Trust A made the correct clinical decision to not insert a mesh.
44. Overall, we have seen the Trust acted in line with guidance when it conducted Mr N’s laparoscopic appendicectomy. For this reason, we will not take any further action on the part of the complaint.
Trust A should have recognised and treated Mr N’s hernia before April 2024
45. Mr N had an appendicectomy on 1 September 2023. Mr N had post-operative complications including an infection which led to a drain being fitted. Mr N had to attend hospital on multiple dates between 14 September and 1 November for issues related to those complications.
46. Mrs N told us after November; Mr N experienced a new symptom of sharp stabbing pains. She says he kept going back to Trust A with the sharp stabbing pains.
47. Mr N’s medical records from his A&E attendance on 1 December 2023 show Trust A examined Mr N’s abdomen and noted no tenderness around the operation site. Trust A could find no evidence of infection or redness around the operation site. Mr N was given antibiotics for any possible infection around the operation site and advised to take paracetamol.
48. On 19 December 2023, Mr N attended a planned outpatient appointment where his abdomen was examined. The doctor noted his abdomen was soft and not tender with some granulation tissue at the operation site. Granulation tissue is a sign of wound healing. Mr N was given an antacid to treat symptoms of stomach acid, and a medication to lower stomach acid levels.
49. Mr N told us he was still experiencing pain from December to March. Mr N told us he chose to just get on with the pain and try and continue with his daily life. Mr N took the medication and trusted Trust A had given him the correct diagnosis.
50. On 6 March 2024, Mr N attended A&E with shortness of breath and a cough. Mr N also reported pain around his belly button. His records show Trust A examined his stomach and considered his history of hernias. Trust A could not feel a hernia at this appointment.
51. Trust A suspected Mr N may have a viral cough. It noted this cough would cause muscle strain in his abdomen causing pain. Trust A did a CT scan of his lungs. No abnormality was seen on the CT scan, and Mr N was given antibiotics for his cough.
52. On 10 April, Mr N attended A&E with abdominal pain. Clinical records show a change of symptoms. Mr N said the pain had started after eating, he felt faint, looked pale and had vomited. Mr N’s abdomen was examined by the doctor. Trust A could see Mr N’s abdomen was soft and tender around the belly button and it ordered a CT scan.
53. On 15 April Mr N had a CT scan. On 16 April, Mr N had a follow up clinic appointment to discuss the findings of the CT scan. The scan showed a para-umbilical hernia containing fat and small bowel.
54. Trust A placed Mr N on a waiting list for urgent hernia repair. At this stage, Mr N realised he may have been wrongly diagnosed in earlier checks, and he had reason to complain. On 6 May Mr N had a hernia repair operation.
55. We discussed Mr N’s care with our adviser to help us determine what should have happened.
56. GMC guidance says medical professionals should adequately assess a patient’s condition considering their history and symptoms. They should carry out a physical examination when necessary and promptly provide advice or investigation.
57. We can see Trust A examined Mr N’s abdomen on each occasion he attended A&E. It looked for any signs of a hernia on 6 March which demonstrates it considered Mr N’s history of hernias. On 10 April, Mr N had a change of symptoms, and a CT scan was promptly arranged so Trust A could further investigate. Our adviser explained the examinations were in keeping with what would normally be expected of his presenting condition.
58. We consider Trust A acted in line with GMC guidance and investigated Mr N’s symptoms appropriately. We can see Mr N regularly attended Trust A from 2023 to 2024. We appreciate this would have been extremely distressing and upsetting. Weighing up the evidence we have seen no indications the hernia should not have been identified any sooner than it was. For this reason, we are taking no further action regarding this part of the complaint.
Trust B
59. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mr N has claimed.
Trust B removed Mr N’s staples too early on 14 May 2024
60. Mr N had his hernia operation on 7 May 2024. The Trust stapled Mr N’s operation cut closed. Mr N’s discharge letter said Mr N had an open repair of a paraumbilical hernia. Mr N was told to complete his antibiotics and have his staples removed in 14 days’ time. This would have been on 21 May 2024.
61. Trust B’s records show it visited Mr N at his home on 10 May 2024. It told him he should book into his local GP Practice to have his surgical staples removed. Mr N attended his GP Practice and had the surgical staples removed on 14 May 2024.
62. Mrs N told us when Mr N arrived home from the staple removal, he had some food with his medication. Mr N felt something on his stomach and saw blood on his shirt. Mr N contacted the GP Practice who advised Mr N to attend Trust A’s A&E.
63. Trust A’s records show Mr N arrived at A&E that afternoon. Trust A noted Mr N was clinically well and the wound had come apart in two places. Mr N’s wound was dressed with gauze and dressing. Mr N was given pain relief with safety netting instructions and a sick note for his employer. Mr N was referred for follow up dressings and discharged around 12 hours after arrival.
64. In its complaint response, Trust B said the nurse’s instruction to remove the staples was an error and should not have happened. Trust B apologised for the error and said the nurse responsible would reflect on the complaint and make sure in future, they thoroughly read discharge information.
65. NMC guidance says nurses should work co-operatively and practise effectively. In line with this guidance the nurse should have followed the direction of the surgical team and sought clarification if the discharge notes were unclear. The Trust has recognised the nurse did not review the discharge instructions as expected and we are not satisfied they have acted in line with the NMC guidance. There is an indication of a failing.
66. Mr N told us the impact of this was he has now developed a much bigger scar because his wound opened up. Mr N told us every time he sees this scar, he is reminded of the pain he was in.
67. We spoke to our adviser to see if we could connect Trust B’s failing to Mr N’s claimed impact. Our adviser told us the length of Mr N’s scar is the length of the surgical cut made in his hernia operation.
68. Our adviser told us the opening of the wound would only impact the width of the scar and not the length. Our adviser explained unfortunately even when staples are kept in place for the correct length of time, wounds can still reopen.
69. We recognise Mr N’s scar may be somewhat wider and therefore bigger because the staples were removed earlier, but we also see the wound was clinically assessed on the same day and redressed accordingly. The Trust did not decide it necessary to re-staple the wound.
70. We cannot know how Mr N’s scar would have healed had the staples remained in place and how much different it would have been in size. We have not seen any evidence this would have been a substantial difference.
71. Mr N told us this also had an emotional impact on him, as he had to visit A&E and he experienced concern the staples were removed too early. We recognise the worry this would have caused Mr N. We note the wound was assessed, dressed and he was discharged within 12 hours of attending A&E. For this reason, we consider the period of worry to be relatively short.
72. Mr N told us he would like an acknowledgement of the failings and an apology from the Trust, service improvements and a financial remedy.
73. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right, identify learning and use it to improve services.
74. The Trust has recognised the error, apologised and explained the action it has taken with the nurse involved to prevent this happening again. This action is what we would expect to see in a complaint of this nature, and in keeping with our Principles for Remedy.
75. We considered this emotional impact Mr N explained against our severity of injustice scale. Level one is defined as a low impact injustice such as annoyance, frustration, worry, or inconvenience. This impact will continue for a short time and have no ongoing wider impact. For this type of injustice, we would usually recommend the organisation apologise to put the complaint right. We would not recommend a financial remedy.
76. We consider the impact Mr N has described to be in line with level one of our severity of injustice scale. We can see Trust B have apologised to Mr N. We consider Trust B has already done enough to put Mr N’s complaint right. For this reason, we will not consider this part of his complaint any further.
Trust B’s communication with the local GP Practice about the redressing of Mr N’s wound was poor between 14 and 22 May 2024
77. Mr N’s records show on 16 May 2024, Trust B referred Mr N to his GP Practice (the Practice) for wound redressing.
78. On 17 May Mr N attended the Practice. It looked at the wound and said it could not dress it, and it should be done by community nurses from Trust B. Trust B visited Mr N at home on 18 May for the redressing of his wound. This was a one-off visit and Trust B then referred Mr N back to the Practice for his wound redressing.
79. On 20 May Mrs N called Trust B to say the Practice could not do Mr N’s dressings because his wound still needed to be packed. Packing a wound involves filling a wound with gauze to promote healing.
80. On this day Trust B visited Mr N and dressed his wound. Trust B could find no cavity present and found the Practice could do the dressings. Mr N was referred to the Practice. From 22 May the Practice began dressing Mr N’s wound.
81. Mr N told us the back and forth between the Trust and the Practice caused him inconvenience. As stated above, he told us he would like an acknowledgement of the failings and an apology from the Trust, service improvements and a financial remedy.
82. Mrs N explained this caused between four and five weeks of stress and inconvenience for Mr N. We can see this was a shorter period than Mr N complained of. We can see it amounted to one week of inconvenience. Despite the difference, we recognise this was still frustrating and distressing for Mr N.
83. In the Trust’s complaint response, it apologised for the communication issues with the Practice. Trust B said it regrets the inconvenience it caused Mr N. It recognised this could be improved and ensured clearer communication and collaboration with this GP Practice in future. This is in keeping with what we would expect to see in a complaint of this nature and in line with our Principles for Remedy.
84. We consider the impact is also in line with level one on our severity of injustice scale, as explained above. We have not seen any justification for a financial remedy.
85. We considered what Trust B has already done enough to put Mr N’s complaint right. We hope this reassures Mr and Mrs N that the appropriate action has been taken. For this reason, we will not be taking any further action on this part of the complaint.
Conclusion
86. We can see Mr N had a lot of post-operative complications that impacted his work, daily life and mental health. We are sorry to hear about this. We hope our findings have reassured Mr N his concerns were taken seriously by Trust B who have now made improvements to make sure this does not happen again. We would like to thank Mr and Mrs N for bringing this complaint to us.