Guy's and St Thomas' NHS Foundation Trust

7. Miss X complains about the care and treatment that Guy's and St Thomas' NHS Foundation Trust provided to her daughter, Miss Y in 2024. She complains that:

• she was not told about the possibility of Junctional Ectopic Tachycardia (JET) prior to Miss Y’s surgery • Miss Y was underdosed in her medication.

• it took almost a week for creams to be given for pressure sores around nappy area • there were multiple failed attempts to place a cannula in Miss Y’s hand • the nursing assistant was rude to her, and she felt that they talked down to her.

8. Miss X says the impact was that:

• Miss Y suffered with JET which required further hospital monitoring and management • Miss Y suffered with pressure sores which caused her pain • she suffers from post-traumatic stress disorder (PTSD)/anxiety about Miss Y in intensive care and being treated badly • she feels she cannot go to this hospital again and therefore treatment is being delayed whilst Miss Y’s care is transferred.

9. Miss X states she would like an outcome of service improvements and a financial remedy.

10. Miss Y underwent an elective Tetralogy of Fallot repair (surgery to repair a heart defect that if left unrepaired could lead to a shortened life span) at the Trust in 2024.

11. Whilst in hospital Miss Y’s heart rhythm changed to JET. She also struggled with haemophilus influenzae pneumonia (a bacterial lung infection) during her time in hospital.

12. Miss Y was an inpatient in hospital for 13 days.

19. 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 consider any gaps between the two and whether this amounted to a maladministration or service failure. We have done this and have not found any indications that something has gone wrong.

Junctional Ectopic Tachycardia (JET)

20. Miss X says she was not informed one of the possible side effects of an elective Tetralogy of Fallot repair was JET. She says Miss Y suffered from JET whilst she was in hospital and this led to her needing further medication and having to spend a longer period of time in hospital.

21. Guidance from the children’s heart clinic given to Miss X says a typical length of stay in hospital after this surgery would be six days. Miss Y was in hospital for 13 days. Adviser A explained JET and the lung infection Miss Y acquired whilst in hospital would be expected to increase the length of stay to between 10-14 days and sometimes longer.

22. Guidance on decision making and consent says when discussing complications and side effects ‘it wouldn’t be reasonable to share every possible risk of harm, potential complication or side effect.’ It says, ‘you should usually discuss any recognised risks of harm that you believe anyone in the patient’s position would want to know.’

23. Adviser A explained JET is a cardiac arrhythmia (irregular heartbeat) and occurs commonly in infants’ having heart surgery. They explained it is a recognised feature of Tetralogy surgery, and it would be considered and encompassed into the risk and complications to organs, or in this case the heart. They explained consultants would usually explain the possible complications broadly as it would not be possible to go into every possible potential injury.

24. We have looked at the medical records and consent forms that Miss X signed prior to Miss Y’s surgery. This lists the potential risks as death, stroke, bleeding, infection, temporary organ dysfunction (heart, lungs, kidneys, bowels, liver) pacemaker and future procedures.

25. We can see the Trust informed Miss X a potential complication of this surgery was that there may be temporary organ dysfunction to the heart. We also understand from adviser A that JET would be encompassed into the risk and complications to organs. We can also see from guidance it would not be reasonable to go into every possible potential side effect for each organ but reasonable to explain there may be complications to this organ.

26. We consider the Trust acted in line with policy and guidance. The Trust correctly identified there may be a temporary organ dysfunction to the heart and discussed this with Miss X prior to her signing the consent form. We consider Miss X was appropriately informed about the potential complications of the surgery prior to consenting.

27. We do not see a gap between what should have happened and what happened in relation to this complaint.

28. For these reasons we will not consider this issue further.

Medication

29. Miss X says in August 2024 during Miss Y’s stay as an inpatient at hospital she was underdosed in her medication. Miss X says she heard nurses discussing increasing the amount of medication Miss Y was on and says she felt there must have been a mistake in the amount of medication Miss Y was on prior to this. Miss X does not know which medication was being discussed.

30. Adviser B says it appears Miss X is talking about a change in the amount of morphine being given to Miss Y as this was the medication that altered in variation on the day Miss Y mentioned.

31. The medical records show Miss Y was on 20mc/Kg/hr (micrograms per kilogram of patient weight per hour) of morphine however, appeared unsettled so this was raised to 25mc/Kg/hr. Miss Y’s morphine was then reduced back down to 20mcg/Kg/hr the following day when she no longer needed the increased dose.

32. Guidance from the British National Formulary for Children states the normal range of morphine for children of Miss Y’s age would be between 20-30mcg/KG/hr which can be adjusted according to the response of the patient.

33. We consider the Trust acted in line with policy and guidance. The Trust correctly kept within the normal range of morphine for children when administering this drug to Miss Y. When she became unsettled this was adjusted to provide further care to the patient and when the increased dose was no longer needed this was then lowered.

34. Considering the above evidence we do not see a gap between what should have happened and what did happen for this complaint.

35. For this reason, we will not consider this complaint any further.

Nappy area

36. Miss X says the Trust took over a week to provide the appropriate care to Miss Y when she suffered with pressure sores around the nappy area.

37. When looking at the medical records we can see Miss Y experienced loose stools during her time in hospital.

38. The day after this occurred Miss Y developed a nappy rash and soreness on the bottom area.

39. The following day the Trust gave care of close observation and repositioning every four hours to prevent pressure sores.

40. The next day the Trust noted Miss Y had a sore nappy area and Miss X had provided care for all Miss Y’s needs.

41. The following day the records note Miss Y’s bottom was dry and intact and barrier cream was being used.

42. Adviser B has explained when children and infants have cardiac surgery, a large portion of their fluid allowance will be taken up with medication. They explained this will mean their nutrition it not optimal and will commonly lead to constipation and loose stools which may cause nappy rash.

43. Adviser B explained the Trust provided Miss Y with lactulose and continuous care to treat this.

44. Adviser B suggested the Trust could have provided further documentation for the medical records on the day Miss X took over care of Miss Y’s needs as it could have asked Miss X for further updates. However, adviser B explained this did not impact the care and treatment provided to Miss Y.

45. We have not seen that there was a delay in providing creams to treat Miss Y’s nappy soreness. We can see the day before Miss Y experienced loose stools, which caused the bottom soreness, Sudocrem (an antiseptic healing cream) was being administered as a preventative measure.

46. When Miss Y’s bottom became sore, this was observed by staff, further steps were taken to attempt to help this such as repositioning every four hours and when this problem continued 48 hours later a barrier cream was applied.

47. Based on the available evidence to us we cannot see the Trust has fallen below the standards expected when providing care and giving creams to Miss Y.

48. We do not see a gap between the care and treatment that should have been provided and the care and treatment that was provided in relation to this complaint.

49. For these reasons we will not consider this issue further.

Cannula

50. Miss X says there were failed attempts to place a cannula into Miss Y’s hand during her time in hospital. She says on one occasion there were three or four attempts made by a nurse to place a cannula into Miss Y’s hand before the nurse decided to seek a doctor’s advice and a cannula was put in via ultrasound.

51. Guidance on paediatric life support states that providers should not spend more than five minutes to establish IV (intravenous) access.

52. Adviser A says a medical professional should not carry out more than three attempts for vascular access before looking for a more senior member of staff to attempt this.

53. Adviser A also says whilst Miss Y was in paediatrics all vascular attempts should be carried out by a doctor and there is nothing to suggest in the medical records that this was not the case.

54. We have considered the medical records and have not found any times when vascular access has been noted as being difficult or when more than three attempts have been carried out.

55. We have carefully considered both accounts of these events.

56. We have conflicting accounts of these events.

57. We have independently considered all the available evidence to see if we can reach a view about what happened.

58. We are unlikely to be able to reach a view there were repeated attempts made by a nurse to administer a cannula for Miss Y. This is because we were not present and there is no further evidence around these events. This does not mean we do not believe Miss X’s account, simply we do not have any supporting evidence to reach a balanced view.

59. For these reasons we are unable to make a decision on this complaint and there will not consider this issue further.

Rude staff

60. Miss X says whilst she was looking after Miss Y in hospital there were members of the nursing staff who were rude to her, and she felt as if they talked down to her. Miss Y explains the nursing staff made comments about her being a first-time mother, fed her daughter when she was not hungry and she felt their behaviour with other staff members was not acceptable.

61. The Trust says it has spoken to this member of staff and provided this feedback to them.

62. The Trust says this member of staff has reflected on her interactions and after long discussions about this has apologised for her behaviour.

63. The Trust has also explained this member of staff has taken on further learning of how parents can be supported during admission, and how important communication and behaviour is.

64. We have considered the actions the Trust has taken to address the indicated failings, in line with our Complaint Standards and whether they have done enough to put this right. We can see the Trust has apologised for this, provided feedback to those involved and has explained how it has learnt from this experience. These are actions we expect to see.

65. We therefore consider the Trust has taken this concern seriously and has taken appropriate action to improve its service.

66. We consider these actions appropriate to address the concerns raised and we do not see indications to suggest further action is needed.

Conclusion

67. We recognise this complaint has caused Miss X considerable distress and worry. We thank Miss X for taking the time to bring her complaint to our attention and for sharing details of her experience with us.

68. We hope our explanation brings some reassurance about the care and treatment provided to Miss Y and the learnings taken by the Trust.

1. We have carefully considered Miss X’s complaint about Guys and St Thomas NHS Foundation Trust (The Trust).

2. Miss X says in 2024 the Trust failed to appropriately care for her daughter, Miss Y, when she had paediatric cardiac surgery. Miss X complains the Trust did not tell her about the possibility of Junctional Ectopic Tachycardia (JET) as a possible side effect of surgery. She also complains that the Trust made multiple attempts to place a canula in Miss Y’s hand, did not provide adequate care for pressure sores around the nappy area, underdosed Miss Y in medication and that the nursing staff were very rude.

3. We sincerely appreciate this must have been a very distressing time for Miss X. We hope this statement gives Miss X reassurance we have thoroughly considered her concerns. We are grateful for the time and effort Miss X made in bringing her complaint to our attention.

4. We would like to assure Miss X that for some of her complaints we have not seen indications that the Trust’s care and treatment of Miss Y amounted to a failing.

5. Where we have seen a failing, we consider that the Trust has already done enough to put that failing right.

6. In making our decision, we do not intend to diminish how stressful this time must have been for Miss X.