A practice in the Doncaster area

4. Mr O complains about the Trust’s care and treatment in relation to his hernia. Mr O complains the Trust:

• did not act on his out-of-range blood results • took until 27 September 2023 to perform the surgery.

5. Mr O says the Trust’s actions caused him to experience significant pain. He says due to the pain he became unable to work and had to take long term sick leave. As a result of this, he lost his job.

6. Mr O is seeking financial remedy.

7. The Trust was due to carry out a hernia operation on Mr O on 14 December 2022, which its bookings team brought forwards to 5 December. During his pre-operative assessment on 28 November, the Trust identified Mr O was neutropenic (having a low white blood cell count). On 2 December 2022, the Trust repeated Mr O’s pre-operative blood tests and cancelled his operation due to the tests showing him to still be neutropenic.

8. Mr O had an appointment with his GP Practice on 8 December, where he informed it of the cancelled operation and his low white blood cell count. His GP Practice arranged a repeat blood test.

9. The Practice completed blood tests on 12 December, 30 December 2022, 3 February, and 27 February 2023. On 28 February the GP sent an advice and guidance request to the Trust haematology department for advice on whether to re-refer Mr O for surgery. On 7 March, the Practice re-referred Mr O to the Trust for his hernia repair surgery.

10. The Trust saw Mr O on 20 May in its general surgery clinic. The surgeon added him to the waiting list for surgery as a category three patient. Patients are categorised between one and four, with one being the most urgent and four being least urgent. Category three procedures should be performed in less than three months.

11. The Trust initially gave Mr O an appointment for day surgery of 27 August. On 16 August the Trust carried out a pre-surgery assessment and found Mr O fit for surgery. However, it identified Mr O did not have anyone to care for him after surgery and would therefore be unable to have day surgery. It listed him for inpatient surgery on 31 August.

12. On 31 August Mr O attended the Trust for his hernia operation. He was listed for afternoon surgery. However, the Trust discharged him without operating. This was due to the Trust not having enough theatre time or staff available to complete the procedure.

13. On 27 September the Trust performed the hernia repair surgery. It discharged Mr O on 28 September.

Trust actions regarding out-of-range blood results

17. Mr O complains the Trust did not act on his out-of-range blood results. He says this caused him to experience significant pain due to delaying his surgery.

18. In the Trust’s initial response to Mr O’s complaint, it stated the plan was for his GP to review the results and arrange any further investigations. It explained that it is the process within the Trust for patients to be referred back to their GP for further investigation where abnormalities are identified with blood test results. It went on to say the GP would refer the patient back into the system via the consultant’s secretary following which the patient is then put back onto the waiting list for their treatment.

19. On reviewing Mr O’s GP records, we could find no evidence the Trust had referred him back to his GP regarding his 28 November and 2 December 2022 out of range blood results. We contacted the Trust and asked it to review its records and confirm if it had referred Mr O back to his GP.

20. The Trust responded to say it had been unable to find any record of communication with Mr O’s GP. It stated, there was an indication to the nurse that Mr O informed her he had already been referred to the GP, so she did not follow this up.

21. GMC Good Medical Practice section 15c states you must refer a patient to another practitioner when this serves the patient's needs.

22. We considered whether the Trust should have referred Mr O directly to haematology or whether it should have referred Mr O back to his GP.

23. We requested the Trust’s haematology referral criteria. It explained it does not have written protocols or guidance for haematology referral but takes internal advice if routine bloods are way above or below normal.

24. We understand from our haematology adviser that as Mr O’s abnormal blood results showed only mild neutropenia, the correct referral route for further investigations would have been to refer Mr O back to his GP. This is because for mild neutropenia the responsibility of initial investigation is with the GP in line with the GP Contract. This says GPs must provide services for the management of patients, including conducting further investigations as is necessary and appropriate.

25. Our ‘Principles of good administration’ say organisations should follow their own policy and procedural guidance, whether published or internal. The Trust’s response to Mr O explained its procedure was to refer patients with abnormal blood results back to their GP.

26. Based on Mr O’s GP records and the Trust’s response, we have found, on the balance of probabilities, the Trust did not refer Mr O back to his GP for further investigations into his out-of-range blood test results. This is not in line with GMC Good Medical Practice, or our ‘Principles of good administration’ and we therefore consider this to be a failing.

Impact

27. Mr O says the Trust’s actions caused him extreme pain. He explained this is because the Trust delayed his hernia operation which it had told him he needed to cure the pain caused by his hernia.

28. We looked at whether the Trust’s actions in not referring Mr O back to his GP would have caused a delay to his treatment.

29. The Trust records show it identified Mr O had out of range blood results on 28 November 2022. It acted on these by doing repeat blood tests on 2 December, which it identified as also being out of range.

30. Mr O’s GP records show it performed repeat blood tests on 8 December, 12 December, 30 December 2022, 3 February, and 27 February 2023. We can also see the GP practice took advice from haematology on 28 February, in response to which it re-referred Mr O back to the Trust for his hernia operation.

31. We understand from our GP adviser that had the Trust referred Mr O back to his GP, the GP would have taken the same actions. This is because Mr O was able to inform the Practice his surgery had been postponed due to his blood count being low. The Practice then acted promptly on this information by repeating his blood tests and taking advice from haematology.

32. Given that the Practice would have taken the same actions had the Trust completed the referral, as it did without a referral, we cannot link Mr O’s claimed impact of extreme pain with the identified failing. This is because we are unable to say the Trust’s actions led to any delays in Mr O’s care and treatment.

Operation date

33. Mr O complains the Trust took until 27 September 2023 to perform the surgery. He says the Trust’s actions caused him to experience significant pain. He says due to the pain he became unable to work and had to take long term sick leave. As a result of this, he lost his job.

34. The Trust then explained Mr O’s GP had referred him back to it on 7 March 2023, after which he was seen in clinic on 20 May and added back onto the surgical waiting list. It stated it initially listed Mr O for day case surgery on 27 August but moved this to inpatient surgery on 31 August, after identifying during his pre-operative assessment that Mr O had no one who could stay with him at home to provide post operative care.

35. The Trust went on to explain that it had had to cancel Mr O’s surgery on 31 August due to cases before him requiring longer than planned surgical time, resulting in staff not having sufficient time to complete Mr O’s surgery. The Trust rearranged the surgery and completed it on 27 September. It apologised to Mr O for the difficulties he experienced arranging a surgery date.

36. During our initial consideration of the complaint, we saw no indication the Trust did anything wrong when it cancelled Mr O’s December 2022 surgery and removed him from the waiting list at that point. This is because he required referral for further investigations before being ready for surgery. Our general surgery adviser explained a patient should only be listed for surgery if they are fit and able to have the operation.

37. We have therefore not considered this period of time any further in our detailed investigation. In this investigation we have specifically looked at the time the Trust took to perform Mr O’s surgery after his GP re-referred him on the 7 March 2023.

38. The NHS constitution states patients have the right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible.

39. The NHS constitution handbook sets the maximum waiting time for consultant-led treatment at 18 weeks from referral for non-urgent conditions. The NHS referral to waiting time rules state a waiting time clock starts when any care professional or service refers to a consultant-led service, with the intention the patient will be assessed and, if appropriate, treated.

40. The NHS constitution handbook provides a summary of the NHS commissioning regulations but does not contain the legal details within the regulations. Regulation 45 sets out the duty to meet maximum waiting time standards. Part 3 of section 45 states, ‘A relevant body must make arrangements to ensure that at the end of each data collection period, not less than 92% of the persons falling with paragraph (4) have been waiting to commence [appropriate] treatment for less than 18 weeks.’

41. We have identified three periods of time during which Mr O had to wait for the Trust to perform his operation. These are: initial referral to initial operation date; change from day surgery to inpatient surgery; postponement due to insufficient theatre time.

42. Mr O’s GP referred him to the Trust for consultant led treatment for his hernia on 7 March 2023. Based on the guidelines set out in the NHS constitution, it should have completed Mr O’s treatment by 11 July 2023. However, the underlying NHS commissioning regulations make it clear that this is a target for commissioning bodies (such as integrated care boards and NHS England) to achieve for 92% of patients.

43. As such, we cannot say the Trust’s failure to complete Mr O’s surgery within 18 weeks is a failing, because we cannot apply the regulations to individual patients. Therefore, the Trust’s decision to list Mr O’s individual surgery after 11 July does not breach NHS commissioning regulations. We cannot consider whether the Trust met its 92% target overall, as this falls outside of the scope of this investigation.

44. The Trust initially listed Mr O for day surgery on 27 August. During his pre-operative assessment on 16 August, it identified that Mr O did not have anyone at home to care for him. As a result, it changed his surgery to inpatient surgery and moved it back to 31 August.

45. AoA guidance for day case surgery says it is essential a responsible adult escort a patient home. It explains the amount of time a carer is required to be in a patient’s home is dependent on the complexity of the surgery being performed.

46. We understand from our general surgery adviser that patients having undergone general anaesthetic require monitoring after surgery. Mr O did not have anyone who could monitor him at home. Therefore, the Trust’s decision to remove Mr O from the day patient list and relist him for inpatient surgery was in line with the AoA guidance for day case surgery.

47. The Trust rebooked Mr O for inpatient surgery on 31 August. However, it then cancelled his operation on the afternoon of 31 August. This was due to the Trust running out of theatre time on the day of the surgery.

48. Our general surgery adviser explained that unfortunately, this can happen and when it does the NHS constitution says treatment should be rescheduled within 28 days. The Trust rescheduled Mr O’s surgery for 27 September and completed it on this date. This was in line with the NHS constitution’s guidelines on rescheduling treatment.

49. Overall, we have found the Trust’s initial scheduling of Mr O’s surgery did not breach NHS commissioning regulations. We have also found the Trust’s actions when rescheduling Mr O’s surgery on 16 August and 31 August were in line with the AoA guidance for day case surgery and the NHS constitution respectively. We understand it would have been very frustrating for Mr O to have to wait beyond 18 weeks.

50. As such, we have found the Trust acted in line with guidelines.

51. We recognise Mr O’s hernia caused him substantial pain whilst he was waiting for surgery and are sorry for the impact this had on his day-to-day life, including his ability to work.

1. We have found Bassetlaw Teaching Hospitals NHS Foundation Trust (the Trust) failed to act on Mr O’s out of range blood results when it should have. We have considered the impact of this failing and have determined that it would not have changed Mr O’s outcome.

2. We have also found nothing went wrong with the time the Trust took to perform Mr O’s surgery after his GP re-referred him in March 2023.

3. We are therefore partly upholding Mr O’s complaint.