The Trust performed an unnecessary appendectomy
16. GMC Good Medical Practice says what clinicians should do to provide good clinical care:
‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options.
‘In providing clinical care you must:
a. adequately assess a patient’s condition(s), taking account of their history, including i. symptoms ii. relevant psychological, spiritual, social, economic, and cultural factors iii. the patient’s views, needs, and values b. carry out a physical examination where necessary c. promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.
17. On 21 June 2024 Ms A went to the Trust with tenderness in her abdomen and flanks. Our adviser said Ms A’s presentation was consistent with a potentially inflamed appendix.
18. A Trust doctor performed a physical examination and then arranged for a computer tomography scan (CT scan – which takes detailed images of inside the body) of Ms A’s abdomen. The Trust actions in assessing Ms A and then ordering investigations are in line with the guidance above. Our adviser confirmed the CT scan was the correct investigation to request to confirm (or otherwise) a diagnosis here. They said the result of the CT scan was consistent with a diagnosis of appendicitis.
19. Our adviser said a second CT scan to confirm the diagnosis was not necessary and would not be recommended in view of the ionising radiation exposure. Investigation of the appendix after the operation confirmed she had appendicitis.
20. We are satisfied Ms A’s symptoms, and the Trust assessment and investigations were all consistent with a diagnosis of appendicitis. Ms A’s appendix did need come out.
21. Appendicitis is a painful urgent medical condition caused by inflammation of the appendix, often resulting from a blockage. Delaying treatment is not recommended. Serious life-threatening conditions can result from a burst appendix. Our adviser said it would have been inappropriate for the Trust to have allowed Ms A to fly home for delayed treatment. There would have been increased risk to Ms A of further complications during her flight as well as deep vein thrombosis (DVT). Our adviser said flying with appendicitis is not recommended.
22. We have seen no indication the Trust did not act in line with GMC guidance. It carried out appropriate investigations to diagnose appendicitis and correctly treated it as an urgent matter.
23. We were sorry to learn of how Ms A has been affected by this and with health going forwards.
The Trust failed to identify her kidney infection as the primary problem
24. The GMC guidance quoted at the start of the previous section is also relevant here.
25. When Ms A presented with further abdomen and flank pain after her operation the Trust assessed her and ordered an ultrasound scan. The Trust diagnosed Ms A with nephritis (a painful inflammation of the kidney) and began treating it with antibiotics.
26. Our adviser said it was appropriate for the Trust to concentrate on Ms A’s most urgent problem, the appendix. Treating Ms A for a kidney infection first would not have changed the outcome here. Ms A’s appendix needed to be removed urgently and this was the priority. Our adviser said leaving it in for longer than necessary, while looking at a kidney infection, would have increased the risk of further complications to her.
27. We are satisfied the Trust prioritised and concentrated on Ms A’s most urgent problem, the appendix, and its actions were in line with GMC guidance from the previous section.
28. Although we cannot see the Trust did anything wrong, we acknowledged Ms A had a painful and upsetting experience. She required medical intervention in a foreign country and hospital admission for several weeks incurring unexpected costs. We understand and are sorry to hear she has continued to have health problems ever since. We hope she can be reassured the Trust’s action in removing her appendix was necessary.
The Trust told Ms A her treatment would be free
29. We have established above that the treatment the Trust provided was necessary.
30. The National Health Service (Charges to Overseas Visitors) Regulations 2015 is the law on charging overseas visitors for NHS treatment. The DHSC guidance explains the application of those regulations in more user-friendly language.
31. The DHSC guidance explains that ‘throughout the process of identifying overseas visitors, it is important that patients are made aware as soon as possible that there may be a charge for treatment. Failure to inform patients as soon as possible about charges may result in an invoice being presented to a person who was not aware that they were liable and could result in accusations of maladministration. However, under the charging regulations, even when a relevant body has failed to inform a patient of charges, and subsequently a patient is found to be chargeable, the patient is still liable for that charge’
32. The Trust in its response noted a documented conversation Ms A had with her clinicians who told her fees would be waived due to being classed as an emergency. There is an indication of a failing here in the Trust’s communication because her treatment was chargeable.
33. Ms A says she was shocked when told what she would be charged and says if she had been informed before her operation, she could have made alternative choices about her treatment.
34. We agree it would have been frustrating and annoying for Ms A to be told her treatment was free only to be told the opposite later. Being presented with a bill would undoubtedly have been a shock for her. But her operation was necessary and we cannot see there were alternative choices available to her at that time. We do not consider better communication would have meant she did not incur the charges.
35. The Trust said it was sorry Ms A was not aware of the charges. The Trust acknowledged Mrs A should have been informed that the overseas team would be notified of her treatment and she would receive an invoice. It apologised of this message was not given or was misunderstood. The Trust said Ms A would still be charged.
36. A level 1 injustice on our severity of injustice scale is one where we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience. This would typically arise from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.
37. The Trust acknowledged it had not told Ms A the right thing about charges and apologised for the impact on her. We consider the Trust apology in line with what we would expect here for the impact of the poor communication. We will therefore take no further action on her complaint.
38. We appreciate Ms A taking time to tell us about what happened. It must have been distressing for her being taken seriously ill while away from home.