Nuffield Health

4. The complaint has been brought to us by Ms I on behalf of her daughter. Ms I complains about the treatment her daughter received from the Trust following her pilonidal sinus surgery on 15 January 2022. She complains:

• the Trust should have used wound packing to protect the wound and allow it to heal after Ms I’s daughter’s surgery on 15 January 2022 • the Trust did not take adequate action to treat Ms I’s daughter’s wound after she reported she was experiencing issues such as the wound opening, beginning 7 February 2022.

5. As a result of the Trust not providing wound packing or suitably treating her open wound, Ms I states her daughter:

• experienced over six months without receiving wound packing • was unable to do daily things she usually would such as go to the gym or wear certain clothes • felt like she smelt badly all the time • started to take a contraceptive pill to stop her periods so no blood would enter the wound • became depressed and had low self-esteem which led to her taking anti-depressants.

6. By bringing her complaint to us, Ms I hopes to achieve:

• an apology for Ms I’s daughter to acknowledge what has happened and the impacts this had • service improvements such as updated policies or extra training to be made within the Trust so that the same issues do not happen to patients in the future.

7. On 15 January 2022, Ms I’s daughter had pilonidal sinus surgery at Nuffield Health as an NHS patient. Pilonidal sinus is a small hole or tunnel in the skin usually filled with fluid or pus that causes cyst or abscess. It occurs at the top of the buttocks. Ms I’s daughter had a procedure to clear the pilonidal sinus and was given absorbable stitches to seal the wound. The Trust stated as the wound was surgically (stitched) closed, there was no need for wound packing. Wound packing is a technique used to control bleeding in deep wounds.

8. On 7 February 2022, Ms I’s daughter attended the Trust as the wound had opened. The consultant surgeon cleaned the area and advised Ms I’s daughter to keep the area clean. Ms I’s daughter was told she would be referred to another consultant (consultant B) to discuss her unhealed wound.

9. On 28 June 2022, Ms I’s daughter had an outpatient consultation via telephone with consultant B. Ms I’s daughter and Ms I explained the wound was not healing and was still discharging. They advised there was no bleeding or pain, but the area was itchy. Consultant B advised Ms I’s daughter should attend the Trust in person so it could assess the wound and decide on the best course of action.

10. On 12 July 2022, consultant B saw Ms I’s daughter in person and confirmed her wound had not healed. They wrote to Ms I’s daughter's GP and made a recommendation for a particular wound packing with calcium alginate (calcium salt based) dressing. The consultant also informed Ms I’s daughter's GP she would need a referral to a plastic surgeon for a skin flap to help with the healing of this area. The consultant says this was also explained to Ms I’s daughter and her mother at the appointment.

11. Ms I advises this was said at the end of the consultation as though a passing comment. She states the option of wound packing was not discussed in detail with them.

12. Ms I explains she rang her daughter’s GP surgery straight away and told it she was going to be discharged and the consultant had mentioned wound packing. The GP surgery explained it had not heard from the Trust for six months.

13. Ms I’s daughter and Ms I then went straight to the GP surgery and were seen by a nurse. The nurse advised they were very surprised to hear the Trust had not referred Ms I’s daughter for wound packing previously, given the nature of the wound.

14. Ms I explains the nurse showed her how to apply the wound packing so that she could assist her daughter at home. Since beginning the wound packing, the wound gradually got better and then healed completely.

15. On 15 July 2022, Ms I complained to the Trust.

16. On 16 August 2022, the Trust provided Ms I with its complaint response letter.

17. The Trust explained although the treatment was being provided at its premises, Whittington Health NHS Trust were hiring theatre capacity from it and Ms I’s daughter remained a Whittington Health NHS Trust patient. The Trust has since apologised for this information and confirmed it was incorrect.

18. Whittington Hospital has informed us Ms I’s daughter was not registered as a patient at Whittington Hospital, nor was she referred by it. It has stated Ms I’s daughter’s GP referred her to UCLH who subsequently referred her to Nuffield Health as part of a contract. We have now seen sight of this contract to confirm the arrangements.

19. Ms I then complained to Whittington Health NHS Trust who responded on 18 July 2023 to explain it would not investigate the complaint.

20. On 1 September 2023, Ms I complained to NHS England on the advice of a POhWER (advocacy service) representative via telephone.

21. On 23 December 2023, Ms I complained to PHSO.

25. Ms I explained Ms I’s daughter started to experience issues such as her wound opening, beginning 7 February 2022. The surgeon stated in the clinic letter following this appointment:

‘I am optimistic that this will heal, but it will require you to clean the surrounding area meticulous daily to prevent faecal contamination, as well as keeping the area dry. You can use water with soap, salted water, or water with an antiseptic. You should then use a pad or gauze to keep the area dry.‘I plan to see you again in four weeks’ time. If the excision wound has healed fully or almosthealed by then, then I will not need to arrange any further review. Failing this, I might consider referring you to another specialist if further intervention is considered necessary.’

26. Our adviser explained the recommended treatment for healing the wound would depend on the depth of the wound and degree of contamination from hair and debris. The surgeon’s outpatient letter suggests there was a considerable amount of wound contamination and so our adviser explained the advice to keep the wound clean in the first instance would be reasonable.

27. The surgeon however, suggested a review of the wound in four weeks’ time but based on the information we have been provided, and the Ms I’s daughter’s relevant medical records, we cannot see this review went ahead.

28. If Ms I’s daughter had been reviewed further at this point as agreed then it would have been in line with General Medical Council (GMC), Good Medical Practice (GMP) 2013, which states under paragraph 15,

‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:

c. refer a patient to another practitioner when this serves the patient’s needs’

29. Wound packing is usually suggested if the wound fails to heal to allow healing by secondary intention. It would be difficult to be definitive without seeing the wound, but it would be expected that Ms I’s daughter be referred to her GP practice nurse for wound care.

Impact

30. Ms I states because of the Trust not suitably treating her open wound, Ms I’s daughter experienced over six months without wound packing. We considered what impact was caused because of the planned review for ‘four weeks’ time,’ not going ahead.

31. The advice provided to us explained that based on the fact Ms I’s daughter’s wound had still not healed, should she have been seen in March 2022 as planned by the Trust, it would have been reasonable to start wound packing at this time.

32. The records show Ms I’s daughter was not seen in person until 12 July 2022 when she was referred to her GP for wound packing by the Trust. We have found Ms I’s daughter’s wound should have been reviewed sooner and had this gone ahead, it is likely she could have received wound packing around three months earlier than she did.

33. Ms I also explains her daughter was unable to do things she usually would such as go to the gym or wear certain clothes along with feeling as though she smelt badly all the time. She says Ms I’s daughter started to take the contraceptive pill to stop her periods so no blood would enter the wound and explains Ms I’s daughter became depressed and had low self-esteem which led to her taking anti-depressants.

34. We are sorry to learn how the continued issues Ms I’s daughter experienced with her wound during this time affected her and can understand this must have been very uncomfortable and upsetting. We appreciate the continued physical impacts Ms I’s daughter experienced will have been distressing for her and can understand this may also have contributed to her experiencing worsened mental health. We have found that should Ms I’s daughter have been reviewed and received wound packing earlier, the impact of these effects could have been prevented or lessened.

1. We have decided to uphold Ms I’s complaint against the Trust. We are sorry to hear of the events that led to Ms I raising her concerns as a complaint. We appreciate this has been very frustrating for both Ms I and her daughter.

2. We have made recommendations for an apology and service improvements.

3. This report has also been shared with University College London Hospitals NHS Foundation Trust (UCLH) so that it may take learning from these events when making future arrangements to outsource treatment to alternative organisations.