Nottingham University Hospitals NHS Trust

5. Mr Beardsall complains about the care and treatment the Trust provided to him between December 2023 and July 2024. He specifically complains:

• the consultant carried out the penile prosthesis procedure ineffectively in December 2023 • staff disbelieved his mobility issue and so provided inadequate care when he was admitted to hospital between February 2024 and May 2024 • the Trust did not discharge him safely or adequately or complete a risk assessment in May 2024 • staff blamed him for presenting with unacceptable behaviour during his admittance in June 2024, rather than understanding his distress and emotional state about his circumstances • the Trust made further failures when it discharged him after a second admittance in July 2024.

6. Mr Beardsall said these experiences have caused him long term devastating consequences.

7. He has since been diagnosed with post-traumatic stress disorder (PTSD) and functional neurological disorder (FND). FND is a condition where there is a problem with the way the brain works, affecting movement, sensation and other functions.

8. He has a great fear of having a sexual relationship for fear of using the implant, causing it to break again and needing to return to hospital. He feels like at the age of 38 is his life is 'done'.

9. The events have left him disabled, he needs to use a wheelchair and now is reliant on daily carers.

10. Mr E is seeking an apology, explanation, service improvements and financial remedy.

11. Mr E has a history of depression, anxiety, personality disorder and a diagnosis of attention deficit hyperactivity disorder (ADHD). ADHD is a neurodevelopmental condition that affects attention, impulse control and hyperactivity. A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person.

12. Mr E has experienced priapism. Priapism is a condition which causes prolonged erections resulting in death of muscle tissue of the penis. A penile prosthesis may be considered as a treatment when the priapism has failed to respond to other measures.

13. In 2017 Mr E had his first penile implant operation. He said the first two implants just lasted a couple of years each.

14. In December 2023 the Trust carried out Mr E’s third implant operation. It discharged him the next day.

15. Two days later Mr E returned to hospital due to some issues with the implant.

16. Five days later the Trust discharge him.

17. In February 2024 the Trust admitted Mr E to hospital because of further issues with the implant.

18. In March 2024 the Trust carried out a revision procedure.

19. At the end of May 2024, the Trust discharged Mr E. Mr E lives in supported living in a second floor flat

20. Two weeks later, the Trust readmitted Mr E through the ED due to further issues with the implant.

21. In July 2024 the Trust discharged Mr E.

22. Mr E has since been diagnosed with Functional Neurological Disorder (FND).

Penile implant procedure

27. 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 have done this and have not found any indications that the Trust carried out the penile implant procedure ineffectively.

28. Mr E told us he had his first penile implant operation nine years ago. He said he was told at this point it should last approximately 10 years. He said this only lasted a couple of years, resulting in his having a second procedure. Again, this only lasted a few years.

29. In December 2023, Mr E went to the Trust for his third implant. He said this only lasted seven weeks. He said he did not even get through the recovery period, or even use it, because one of the cylinders broke free. He said it was stuck in his pelvis, but the Trust could not remove it. Mr E said he was in complete agony and felt he was at risk of it dropping out.

30. In February 2024, Mr E said he returned to hospital because the prosthesis had come undone and was poking out of his body. He said this caused him enormous trauma and he had a mental health breakdown.

31. The Trust said it performed the surgery successfully in December 2023. It discharged him following a full review and assessment. No concerns were indicated.

32. It said Mr E presented at the ED with a suspected post-operative infection. This is a known risk and complication of surgery, according to the signed consent noted in Mr E’s records. It carried out a computed tomography (CT) scan. This is a type of medical imaging device which creates detailed picture of the inside of the body.

33. The CT scan did not identify any issues with the penile implant. The Trust followed this up seven days later and noted good progress and no indication of abnormalities.

34. The Trust said the implant was inserted properly and no abnormalities were discovered. The implant was fully functional with inflation and deflation at both the follow up appointments in January and February 2024.

35. The Trust stressed it did not see any risk or indication for the prosthesis falling out. It added, nationally, there is no risk factors or indications for a penile prosthesis to fall out.

36. The Trust explained one of the recognised complications of a penile prosthetic is the possibility of the device breaking. This occurs at a rate of two percent per year. It also pointed out an impact on durability can be around user usage. It said it provides extensive training to all patients to reduce the risk of breakage, but this does still occur.

37. The BAUS leaflet sets out the risks associated with having the implant procedure and the likelihood of a patient experiencing these risks. These include: • bruising and swelling of the penis – almost all patients • malfunction or mechanical failure of inflatable implants within ten years – one in 20 patients (5%) • erosion of the device requiring further surgery – between one in 20 patients (less than 5%).

38. We acknowledge the BAUS leaflet is dated June 2024, and this is after the event complained about. We are of the views that although the numbers quoted in the leaflet may not be right for 2023, the risk themselves would have been the same.

39. GMC guidance on consent states, ‘all patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able… medical professionals must start from the presumption that all adult patients have capacity to make decisions about their treatment and care’.

40. We can see from records the Trust carried out the penile prosthesis surgery is December 2023. We can see the consent form signed by Mr E which states ‘discussion of specific risks and benefits with patient’. It documents that relevant risks, including device failure and the possibility of further surgery were discussed. This is in line with GMC guidance.

41. We can see Mr E was discharged the next day. The discharge summary states the Trust admitted Mr E for the elective procedure or a change of penile prosthetic. It says, ‘there were no complications in surgery’.

42. Records indicate Mr E returned to hospital several days later. The urology consultant checked the implant and the Trust carried out a CT scan. The discharge summary indicates there was no sign of infection, the wound was clean and healthy. It reported Mr E to be well and medical fit for discharge.

43. Mr E had an outpatient appointment two weeks later. Notes do not indicate any identified problems other than some bruising and swelling. This would be expected according to BAUS leaflet.

44. In January 2024 we can see Mr E returned to the Trust for a further follow up appointment. The GP letter noted, ‘all bruising has now gone down and all his wounds are looking lovely and well healed. Today we inflated and deflated his implant with minimal discomfort’.

45. Following an outpatient appointment in February 2024, the Trust wrote to the GP further saying, ‘from a post-operative point of view, his wound is looking clean, with no signs of bruising or swelling. He was able to inflate and deflate his implant with ease and no discomfort. He is doing very well.’.

46. We asked our urology adviser whether there was evidence the Trust did not carry out the prosthetic implant procedure effectively.

47. They said the records indicate the prosthesis was functioning appropriately at both the January and February appointments. They explained a functioning device at early follow-up is consistent with satisfactory implantation and the absence of early mechanical failure. They highlighted the is no evidence within the records of a complication, incorrect placement or early device malfunction.

48. Our urology adviser said penile prosthesis implantation is recognised to carry a risk of mechanical failure over time and the potential need for further revision. BAUS information sets out the risk of this to happen within ten years to be five percent. Our urology adviser said this risk is increased each time revision surgery take place.

49. They said the occurrence of such a complication does not, in itself, indicate the surgery was not carried out effectively.

50. We understand Mr E’s concerns. We do not doubt he experienced significant pain postoperatively and was worried about the success of the procedure. We are unable to say why he experienced issues with the prosthetic. From what we have seen in records, and discussed with our urology adviser, we cannot see evidence to conclude the Trust performed the surgery incorrectly in December 2023.

Mobility issues

51. Mr E complains about the care nurses provided to him during his admission between February and May 2024. Mr E explained he could not use his legs and struggled to mobilise. He said he was emotionally traumatised and physically incapable of walking.

52. He said he initially used a walking stick, before moving onto crutches and ultimately needed to use a wheelchair. He said the nursing staff disbelieved his mobility issues, ‘huffed and puffed’ when he pressed his buzzer and left him waiting for assistance. He said the Trust did not investigate the issue appropriately.

53. The Trust response does not refer to this part of his complaint specifically but responds to Mr E’s complaints about nursing care and his mobility issues with regards to discharge. These responses will be considered later in the report.

54. NMC standard 4.7 says, ‘demonstrate the knowledge, skills and ability to act as a role model for others in providing evidence-based, person-centred nursing care to meet people’s needs related to mobility, hygiene, oral care, wound care and skin integrity’.

55. NMC Standard 3.16 says, ‘demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention and support.

56. We can see numerous nursing notes dated from March onwards which refer to Mr E’s increased pain and decline in mobility. Several February notes indicate Mr E was mobile and independent, and off ward a couple of times before bedtime.

57. Towards the end of March, notes indicate he was complaining of painful legs. Notes indicate he was experiencing severe pain and requesting medication. We can see notes about him mobilising firstly with a stick, and then with crutches. Notes suggest staff were acting in line with NMC guidance in their awareness and support of his mobility needs.

58. Also, in line with NMC guidance, we can see staff escalated these concerns to the medical team referred Mr E appropriately to the pain team and the physiotherapy team on several occasions.

59. We asked our nurse adviser if they considered staff provided Mr E with inadequate care with regards to his mobility needs. Our nurse adviser said they were unable to see any evidence in the records the nursing staff disbelieved Mr E’s mobility issues and needs. They felt records indicated staff took the concerns seriously and took appropriate action in line with guidance.

60. We are sorry Mr E felt staff were dismissive of his mobility needs, neglected his care and were on occasion rude to him. We cannot make a determination on the of the nature interactions between Mr E and staff during this time. What we can see from records is that staff considered his mobility issues throughout his admissions and made referrals as appropriate. This suggests they were not dismissive of this issue.

May and July 2024 discharges

61. Mr E complains about the way the Trust discharged him in May 2024. He said he was discharged as ‘medically fit’, but he could not walk and was using a wheelchair. He said this was not noted in his discharge records.

62. Mr E said the Trust did not complete a risk assessment and did not offer him any rehabilitation. He said he felt abandoned and trapped in his second floor flat, unable to use the stairs.

63. The Trust explained in its response, it discharged Mr E as medically fit because it had completed all the urology investigations and care.

64. It said in terms of being fit for discharge regarding mobility and daily needs, the Trust had addressed this throughout his admission. It said occupational therapists, physiotherapists and the integrated discharge team were involved in discharge planning. It arranged rehabilitation to his home following discharge.

65. The Trust said risk assessments were carried out as part of his ongoing care. It added both the hospital team and the supported housing team risk assessed Mr E’s home environment. The Trust ordered appropriate equipment for his home to help meet his needs. It organised transport to assist Mr E access his property.

66. NICE guidelines NG27 say, ‘from admission, or earlier if possible, the hospital and community based multidisciplinary teams should work together to identify and address factors that could prevent a safe and timely transfer of care from hospital’.

67. The guidance says the discharge plan should take account of the person’s social and emotional wellbeing, as well as the practicalities of daily living, as well as the consideration of specialist equipment. It emphasises the importance of a multi-disciplinary approach highlighting the following disciplines – doctor, nurse, therapists, mental health practitioner, pharmacist, dietician, specialists in the person’s condition, social worker and housing specialist.

68. Clinical records indicate the Trust established discharge planning early on in Mr E’s admission in line with guidance.

69. We can see in April 2024 a nursing note which indicates the Trust was going to arrange a meeting between Mr E, his housing provider, the integrated discharge team, ward manager and social services. This was due to the recognition Mr E’s physical capabilities had deteriorated and his property was no longer appropriate for him.

70. We can see from records, there was a temporary plan for more suitable accommodation to be located for him. This did not materialise. However, the hospital multi-disciplinary team and the community team put together a discharge plan which included physiotherapy and occupational therapy equipment alongside a care package, to enable the Trust to discharge Mr E back to his flat.

71. We can also see the Trust arranged for him to be followed up in the community by the intermediate care team, who were to provide him with rehabilitation support at home. Plans were also made for his support worker to visit him regularly at home to undertake shopping and cleaning. The mental health team was made aware of the plan.

72. We can see the majority of the disciplines outlined in NICE guidance NG27 were involved in Mr E’s discharge plan specifically doctor, nurse, therapists, mental health practitioner, pharmacist, specialist in the person’s condition, social worker and housing specialist.

73. Our nurse adviser confirmed their view the Trust discharged Mr E appropriately, in line with guidance, with consideration to his needs and living circumstances.

74. They highlighted there is evidence in the notes of good communication between the Trust therapy team and Mr E’s housing manager regarding delivery of equipment, care packages, risk assessments and safety netting.

75. We can see from records Mr E found discussions around his discharge difficult. We understand why he felt vulnerable returning home to a second floor flat when his mobility had deteriorated to such an extent. We cannot find indication the Trust did not consider his needs appropriately. We have found the Trust’s discharge planning was in line with guidance.

76. Mr E said seven days later he returned to the Trust. He said the scar had opened and was leaking puss. Mr E said his mental state was very poor at this time due to the traumas he had experienced.

77. Mr E complains further about this discharge. He said it took an ambulance crew of four to carry him up to his flat which he found distressing, and this added to his trauma.

78. Records indicate the Trust was aware of Mr E’s continued needs and mobility issues. We can see the Trust considered his needs prior to discharge and put a plan in place for post discharge support from the intermediate care team. The plan refers to his support worker, the mental health team and his housing team.

79. We understand how upsetting it must have been for Mr E to return home and have to be carried up the stairs. Again, we cannot say the Trust failed to act within guidance when discharging Mr E on this second occasion.

Behaviour and empathetic nursing care

80. Mr E said as a result of the trauma he was experiencing with regards to the penile implant, alongside the prolonged hospital admissions and deteriorating mobility, his mental health was severely affected.

81. Mr E complains that the Trust, both at the time of the admissions, and within its response to his complaint, has shown no understanding or empathy towards him. He is unhappy with how it has portrayed him within records and within its response.

82. The Trust response refers to a number of specific occasions when staff recorded Mr E was verbally abusive and threatening towards staff. It also refers to a time when Mr E hit out at another patient which was recorded on a body camera. The response states there were multiple incidences throughout the course of Mr E’s stay where violence and aggression towards staff was seen, recorded and documented.

83. In May 2024, the Trust said it held a meeting with Mr E about his behaviour, and they discussed the use of body cameras, and it provided him with the Withholding Treatment from Patients Exhibiting Unacceptable behaviour leaflet.

84. The Trust said the NHS has a legal responsibility to ensure staff safety. It felt Mr E’s behaviour resulted in negative interactions with staff who were trying to provide care and support.

85. The health and safety at work etc Act 2 (1) says, ‘it shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees’.

86. NMC standard 13.4 says, ‘take account of your own personal safety as well as the safety of people in your care’.

87. NICE guideline NG10 refers to the importance of de-escalation. It says, ‘use techniques for distraction and calming, and ways to encourage relaxation, recognise the importance of personal space, respond to a service user’s anger in an appropriate, measured and reasonable way and avoid provocation’.

88. We know Mr E experiences mental health issues. We can see from his clinical records there were concerns from the first admission. Notes say Mr E threatened to kill himself if the Trust did not admit him. There was an initial plan to arrange a psychiatric bed.

89. We can see a couple of psychiatric reviews from March 2024. One reports Mr E was feeling angry with suicidal thoughts. He was agitated and angry during the assessment, becoming more so as the assessment progressed. At this time the Trust considered a period of psychiatric admission would be helpful.

90. A psychiatric review on April 2024 determined a psychiatric admission would not be appropriate for Mr E because he needed a quiet place and the atmosphere would not suit his needs. It is noted he becomes angry quickly and easily irritated.

91. We can see a number of notes throughout the records which indicate Mr E was getting upset and verbally aggressive towards different professional involved in his care.

92. There are notes which indicate he had also become upset with another patient.

93. The Trust decided it was appropriate for staff to use body cameras when providing care to him. This was explained to Mr E in a meeting.

94. We understand Mr E was very upset about his situation and the issues he had experienced with the penile prosthesis. His upset was understandably exacerbated when his surgery was postponed in March 2024 due to a pharmacy issue.

95. His upset appears to be particularly present during conversations around discharge. The Trust says in its response, he tore up his discharge summary.

96. We realise how stressed and upset Mr E was at the prospect of returning home to a second floor flat. We do not underestimate his concerns, particularly in light of his deteriorating mobility.

97. We are sorry he felt the Trust showed no understanding for the reasons behind his upset and the behaviour he was displaying, and he continues to feel it did not demonstrate any empathy.

98. We can see from records staff did try to appease Mr E on many occasions, seeming to make allowances for his behaviour based on his mental health. For example, a note in March 2024 says Mr E had become upset about another patient on the ward. The Trust removed this patient ‘to prevent the situation escalating’. The notes tell us this calmed Mr E down.

99. This is in line with NICE guidance NG10 which states where possible staff should attempt to de-escalate situations involving patients being aggressive.

100. We asked our nurse adviser whether it considered the Trust responded appropriately towards Mr E’s behaviour. They emphasised the Trust had a duty of care to Mr E. However, they also said staff have a right not to feel unsafe or suffer abuse at work. This is in line with the Health and Safety at work etc Act.

101. Our nurse adviser also said staff had a duty of care towards other patients, who could be at risk due to Mr E’s verbally aggressive behaviour.

102. Their view was the actions that staff undertook in terms of involving security and the ward manager to mange Mr E’s behaviour was justified and in line with NMC guidance which says staff should keep themselves and other people safe.

103. Mr E has explained to us the trauma he was experiencing over this time. He has told us about the impact on his whole life. We understand Mr E experience’s mental health issues and recognise the issues with the prosthesis and the hospital admissions will have impacted on these. We are sorry he felt misunderstood. We cannot say the Trust did not respond appropriately to his behaviour.

1. We have carefully considered Mr E’s complaint about Nottingham University Hospitals NHS Trust (the Trust). We are sorry to about the challenges and distress he experienced following his procedure and during his time in hospital. We do not underestimate the impact of his experiences on all aspects of his life.

2. We have considered Mr E’s concerns the Trust carried out the penile prosthesis procedure ineffectively. Following review of records, and with consideration of relevant information, we cannot say the Trust did not carry out the procedure effectively.

3. We also cannot say there are indications of failings by the Trust with regards to nursing care and discharges.

4. We do not intend for our decision to cause Mr E further distress. We hope this report clearly sets out the reasoning for our decision.