Cambridge University Hospitals NHS Foundation Trust

13. The following is intended to be a summary of events to help set Mr D’s complaint in context. We have limited the information to that which is relevant to our consideration.

14. Mr D told us he got food poisoning within 48 hours of visiting a pub on 26 January 2022. On 1 February, his wife, Mrs D contacted the Practice and explained Mr D was suffering from extreme fatigue, muscle weakness, and abdominal pain. The Practice prescribed a medication for indigestion and arranged blood tests.

15. Mr D was taken by ambulance to QEH’s ED on 5 February. He was experiencing nausea, loss of vision, difficulty swallowing, slurred speech, weakness and dizziness. QEH assessed Mr D for signs he had suffered a stroke. Having ruled this out, it diagnosed him with suspected gastritis (inflammation of the lining of the stomach).

16. Mr D told us once he had been discharged from ED and was feeling a little better, he researched his symptoms online. He says it was at this point that he discovered the link between his symptoms and intestinal botulism, a very rare form of botulism where spores of bacteria develop inside a person’s intestines and produce toxin. Botulism is a rare but serious illness caused by a toxin that blocks the nerves and leads to muscle weakness and paralysis.

17. Mr D’s first appointment with QEH was with its neurology department in April 2022. Following this, Mr D had referrals to several other specialists at both QEH and CUH.

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisations have not put right. Having done so, we cannot link the events complained about with the negative impact Mr D has claimed.

21. We are sincerely sorry to hear about Mr D’s ongoing symptoms of muscle weakness and pain, fatigue, difficulty walking, nausea, slurred speech, eye ache, and difficulty swallowing. We do not underestimate the devastating impact these symptoms have had on his life.

22. While we recognise Mr D’s strength of feeling that he has contracted botulism, there appears to be no clinical evidence to support this. We note CUH arranged diagnostic testing for botulism in August 2024. This test identified that the toxin that causes botulism was not detected in the stool sample provided by Mr D.

23. In addition to this, in its complaint response dated 19 February 2025 CUH said its clinical examinations indicate Mr D does not have botulism. QEH said in its complaint response dated 5 November 2024 that it did not identify clinical symptoms of botulism when it examined Mr D in the ED or during further consultations.

24. In its complaint response dated 7 October 2025, the Practice said while it did not refute or ignore the possibility of botulism, Mr D did not have any typical symptoms associated with the condition.

25. The impact Mr D described to us is based on his view that he has botulism and that each organisation he has seen since January 2022 has failed to diagnose and treat it. To link the care each organisation provided Mr D with the impact he claims, we would first need evidence that he had botulism. On balance, we do not consider the evidence supports this.

26. It is important to explain that we cannot reach our own view on whether Mr D had botulism or replace the clinical findings of an NHS organisation with our own. This is not our role. For this reason, we would never be able to conclude that a diagnosis of botulism was missed, that treatment for botulism should have been provided, or that the symptoms Mr D has suffered from since January 2022 resulted from or were worsened by a failure to diagnose or treat botulism. Without clinical evidence that Mr D had botulism, it is not possible to link the actions of each of the organisations with the impact Mr D describes.

27. We recognise Mr D reports ongoing symptoms and that no alternative diagnosis has been identified. The absence of a confirmed diagnosis does not in itself indicate there have been any failings in the care he received. If Mr D believes there have been failings in the management of his symptoms unrelated to botulism, that would be a separate matter which has not yet been considered by the Practice, QEH, or CUH as part of his complaint. He would need to raise these with each organisation in the first instance.

28. We recognise how much of a difficult time Mr D’s ongoing symptoms are causing him. We hope this statement reassures him that we have considered his complaint carefully and clearly explains our decision not to consider the issues further.

1. We thank Mr D for bringing his complaints to us. We recognise how important the issues he raised are to him and the effort he has made to share his experiences with us.

2. We have carefully considered Mr D’s complaints about the Practice, QEH, and CUH. We have decided we cannot link the care Mr D complained about to the impact he claims. This is because we have seen no clinical evidence Mr D contracted botulism, and we cannot reach our own view on whether he should have been diagnosed with this rare disease.

3. For this reason, we would never be able to conclude that a diagnosis of botulism was missed, that treatment for botulism should have been provided, or that the symptoms Mr D has suffered from since January 2022 resulted from or were worsened by a failure by the Practice, QEH, and CUH to diagnose or treat botulism.

The complaint about the Practice

4. Mr D complains the Practice has failed to diagnose him with botulism since February 2022. He says when testing for botulism, the Practice did not send a sample to the correct laboratory. Mr D also says the Practice failed to notify the UK Health Security Agency (UKHSA) that he had suspected botulism.

5. Mr D says because of the failings, he has received no treatment for botulism. He says had the Practice diagnosed botulism at the earliest opportunity, he would not have suffered to the degree he has.

6. Mr D would like the Practice to apologise and acknowledge its failings. He would also like financial remedy.

The complaint about QEH

7. Mr D complains he was misdiagnosed with gastritis when he attended the Emergency Department (ED) on 5 February 2022. He complains QEH has failed to diagnose botulism and provide suitable treatment since February 2022.

8. Mr D says his symptoms have had a devastating effect on his life and he is now disabled. He says he feels ignored and ridiculed by QEH.

9. Mr D would like QEH to apologise and acknowledge its failings. He would also like financial remedy.

The complaint about CUH

10. Mr D complains since he was referred to CUH in July 2023, it has failed to diagnose botulism and offer him a treatment plan. He says CUH relied on laboratory tests to reach its view that he does not have botulism. Mr D also complains CUH failed to provide evidence that it arranged for the correct laboratory to test for botulism.

11. Mr D says his symptoms have had a devastating effect on his life and he is now disabled.

12. Mr D would like CUH to apologise and acknowledge its failings. He would also like financial remedy.