The Newcastle Upon Tyne Hospitals NHS Foundation Trust

4. Mrs L complains about the care and treatment she received from the Trust. She specifically complains that:

• the Trust carried out micro vascular decompression surgery in February 2023 causing detrimental effects to her health • during her admission in February, clinicians dismissed the pain and vomiting she suffered following surgery • some of its staff recorded inaccurate information into her medical notes • it discharged her too early and without a doctor/consultant assessing her • the Trust delayed in arranging a further appointment with the surgeon following the effects of the surgery in February • it misdiagnosed her with a skull fracture and brain fluid leak • the Trust may have either caused Chiari malformation as a result of the surgery in February 2023 or it was a pre-existing condition which the surgery made worse • it refused to re-evaluate her scans it took in August 2022 and 2023 to see if she had Chiari malformation prior to the surgery in February 2023.

5. Mrs L explains the surgery in February 2023 caused damage to her vestibular cochlea nerve, leaving her permanently deaf in her left ear. She says, this also resulted in her having vestibular dysfunction, tinnitus and imbalance. She says she still suffers from pain and pressure in her head.

6. She says she was bed bound for over a week following her premature discharge, and suffered with vomiting. Had she been kept in following her surgery in February, she believes the skull fracture and brain fluid leak would have been found and rectified sooner and she would have recovered quicker.

7. Mrs L says the Trust’s actions caused her to have panic attacks and depression. She says she has been treated for trauma and received counselling and therapy.

8. Mrs L would like an acknowledgement of the failings, apology for the impact caused, service improvements and a financial remedy. She would also like the Trust to review its decision not to compare the scans in 2022 and 2023 to see if she had Chiari malformation before the operation in February.

Chiari I malformation and scans

12. Mrs L complains the Trust may have either caused Chiari malformation (where the lower part of the brain pushes down into the spinal canal) as a result of the surgery in February 2023 or it was a pre-existing condition which the surgery made worse. Mrs L complains the Trust refused to re-evaluate the scans it took in August 2022 and 2023 to see if she had Chiari malformation prior to surgery in February.

13. Mrs L saw a private consultant neurosurgeon in mid-June 2024. They viewed the head computed tomography (CT) scans from March and August 2023 and said Mrs L has Chiari I malformation.

14. Within the Trust’s complaint response dated early September 2024, it said it did not agree with the opinion Mrs L obtained privately from the consultant neurosurgeon that she had Chiari malformation. For this condition to be considered, it said the cerebellar tonsils have to protrude significantly below the foramen magnum (opening located at the base of the skull). It said Mrs L’s tonsils are normally positioned. It said in cases of Chiari malformation, symptoms are rare, and even if she did fulfil the full anatomical criteria for Chiari malformation, nothing about her surgery would have rendered her symptomatic (observable of an illness of medical condition) in the absence of any preoperative symptoms.

15. Regarding reviewing the scans, the Trust did not agree with the private consultant’s view that Mrs L has Chiari I malformation and therefore, did not believe this was visible on her magnetic resonance imaging (MRI) scan from August 2022.

16. Our adviser reviewed Mrs L’s post-operative head scan images and said there is no evidence of a Chiari I malformation. There is a slight descent of the cerebellar tonsils which is in keeping with cerebellar ectopia (low lying tonsils), but as there is no significant cerebellar descent, and there is CSF (cerebrospinal fluid) around the craniocervical junction (where the skull meets the upper cervical spine), there is no evidence of a Chiari I malformation.

17. If Mrs L had a Chiari I malformation prior to surgery in February 2023, our adviser said this was not causing any symptoms, and based on good clinical practice and experience, the Trust would have still carried out the microvascular decompression surgery in February. This surgery would not have routinely made a Chiari I malformation worse.

18. Our adviser said there is no evidence of a Chiari I malformation on the post-operative CT scans. Therefore, in line with clinical experience and practice, there would be no requirement for the Trust to review or re-evaluate the CT head scans.

19. We recognise Mrs L questioning if she has Chiari I malformation, whether this was caused or made worse as a result of the surgery in February 2023, and whether the Trust should have re-evaluated her scans.

20. Informed by clinical advice, there is no evidence in the post-operative scans that Mrs L has Chiari I malformation and therefore there would be no requirement for the Trust to review or re-evaluate the head scans. There is no indication of a failing.

Risks of surgery

21. Mrs L complains the Trust carried out micro vascular decompression surgery (a procedure which aims to relieve pressure from an artery on a cranial nerve — nerves which enter and leave the brain stem directly and pass through the skull base) in February 2023 without fully informing her of the risks.

22. Mrs L has not complained about this to the Trust.

23. Section 4(4) and (5) of the HSC Act 1993 prevents us from conducting an investigation unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.

24. In line with the HSC Act, we cannot investigate this aspect of Mrs L’s complaint. This is because there is no evidence she raised this with the Trust and gave it opportunity to respond.

25. The HSC Act 1993 (Section 9(4)) also says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

26. Even if Mrs L raised this with the Trust now and then brought her complaint to us, it is more than likely we could not investigate. This is because the complaint is significantly outside of the statutory time limit for the Trust and for us to investigate, in line with the HSC Act 1993.

Pain and vomiting, discharge, post operative appointment, diagnosis of skull fracture

27. Mrs L complains:

• the Trust carried out micro vascular decompression surgery in February 2023 causing detrimental effects to her health • during her admission in February, clinicians dismissed the pain and vomiting she suffered following surgery • it discharged her too early and without a doctor/consultant assessing her • the Trust delayed in arranging a further appointment with the surgeon following the effects of the surgery in February • it misdiagnosed her with a skull fracture and brain fluid leak and then later retracted the diagnosis without explanation.

28. We have carefully considered Mrs L’s date of knowledge regarding her individual complaints. To assist us in doing so, we have obtained information from Mrs L during telephone calls with us, documents she has sent to us, including her complaint form and the Trust’s complaint file.

29. Mrs L told us her date of knowledge for these complaints was late December 2023, after receiving her medical records and becoming aware of the inaccuracies within her notes.

30. Informed by our conversation with her and her complaint form, we consider she was concerned about these events when they occurred. We therefore consider Mrs L’s date of knowledge relating to the pain and vomiting following surgery and discharge was by early to mid-February 2023 at the latest.

31. In relation to her concerns that the operation caused detrimental effects to her health, Mrs L was aware of this shortly after the operation and within days of being at home (mid-February).

32. Regarding Mrs L’s complaint about arranging a further appointment, she said her husband rang the surgeon’s secretary for three weeks to get an appointment. This appointment was booked for March 2023. We consider she would have been aware of this problem by late February/early March.

33. Concerning Mrs L’s complaint about being misdiagnosed with a skull fracture and brain fluid, we are of the view she would have reason to complain by mid-June 2023 (as confirmed in her email to the Trust in June 2024), following her consultation with the surgeon.

34. Mrs L did not complain to the Trust about the pain and vomiting, discharge and effects of the surgery until late March 2024 – one year and one month after becoming aware she had reasons to complain.

35. Regarding her complaint about the post-operative review appointment, Mrs L did not complain to the Trust until mid-June – one year and three months after becoming aware she had reason to complain.

36. Concerning the misdiagnosis of skull fracture, Mrs L did not complain to the Trust until late March – nine months after her date of knowledge.

37. We received Mrs L’s complaint form in late July 2025. Her complaints are between one year and one month, and one year and five months outside the statutory time limit.

38. In line with the HSC Act, for us to move the statutory time limit to one side we must be satisfied the explanation given for the delay is reasonable.

39. There are two periods of time when we consider Mrs L could have raised her complaint to the Trust and us sooner than she did. These are between:

• Mid-February 2023 and June (dates of knowledge) and late March and June 2024 (the dates Mrs L raised her complaints with the Trust).

• January 2025 (the Trust’s final response) and late July (date Mrs L sent her complaint form to us).

40. We asked Mrs L why she did not complain sooner.

41. She says she was suffering from mental health problems at this time and panic attacks. She said she saw the mental health team at her GP in November 2023 who prescribed her with medication. She says she first approached an advocate to assist her with her complaint in early March 2024.

42. Mrs L also told us that following the Trust’s final response, she broke down. She also lost her job during this time. She went to solicitors, a couple said no. She had a holiday and ‘wondered whether she could progress it’ [bring her complaint to us].

43. We have carefully listened to Mrs L’s explanation for the delay in complaining to the Trust and then us. We are sorry to learn of the experiences she had.

44. Mrs L had an advocate during most of the complaint process with the Trust, who could have explained about the legal time limits and assisted her in completing a complaint form and bringing her complaint to us sooner.

45. Mrs L could have sought assistance from the Trust’s Patient Advice and Liaison Service (PALS), who would have also explained about the legal time limits.

46. Mrs L made an unrelated complaint to PALS in July 2023, contacted solicitors in 2024 and 2025 and went on holiday. We therefore consider she had the ability and opportunity to raise a complaint with the Trust and bring her complaint to us sooner than she did.

47. Although we recognise Mrs L’s reasons for delay, the onus is on the complainant to make enquiries (with the organisation – in this case the Trust) when they are unhappy with the care and treatment they receive or think they should be receiving. Raising this as a complaint brings it to the attention of the organisation and allows it the opportunity to address the issue and if appropriate offer a suitable resolution.

48. The evidence we have seen indicates Mrs L had the ability and opportunity to raise a complaint with the Trust and us sooner than she did.

49. We recognise the difficulties she faced with her mental health and losing her job. We are not persuaded there was any significant barrier during the majority of the time between the date of knowledge and the point she came to us. Although we acknowledge the distress and experiences she was going through may cause some delay, we are not satisfied the total length of time taken in bringing the complaint to us is reasonable for us to move the statutory time limit to one side. For some of the period in question at least, it seems she chose not to make the complaint, rather than that she was unable to make it.

50. We have considered the length of time her complaint was in local resolution (10 months). Although her complaint was in local resolution for long period of time, Mrs L did not complain to the Trust until between nine months, and one year and three months following her date of knowledge. There was also a further five-month delay following receipt of the Trust’s final response. Even taking the time in local resolution into account, her complaint is considerably out of time so cannot investigate it.

Medical records

51. Mrs L said some of its staff recorded inaccurate information in her medical notes during her admission in early February 2023.

52. The Trust did not accept there was anything wrong with the entries. It provided details of its subject access request (SAR) team to assist her with putting an addendum in the records.

53. Medical records are a legal document, and we do not have the power to change them. We did not investigate Mrs L’s complaints about her admission in February 2023, because they are out of time. If we had investigated her complaint about her admission we would have taken into account her comments about the accuracy of her records.

54. Ms L confirmed she has already asked the Trust to include an addendum in her records.

55. The Information Commissioner's Office (ICO) is set up to uphold information rights, promote data privacy for individuals, and enforce data protection laws. Although we can investigate complaints about data in some situations, as we cannot investigate the majority of Ms L’s complaint we consider she should take her complaint about her inaccurate medical records to the ICO. If it found failings the ICO could recommend the Trust make service improvements. Alternatively, Ms L could seek legal advice and consider challenging the content of her records in court.

56. We are sorry to learn of Mr L’s complaint about the Trust. Our decision is not made without recognition of the impact these events have had on her, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Mrs L’s experience with the Trust. We acknowledge the difficult circumstances around this complaint, and the impact this is having. We acknowledge this was and continues to be a difficult time for her.

2. We have carefully considered her complaint about the Trust. Having done so, and for the reasons set out in this statement, we have decided not to investigate this complaint further.

3. Our decision is not made without recognition of the distressing circumstances around the events.