Calderdale and Huddersfield NHS Foundation Trust

3. Mr E says the Provider’s investigations, diagnosis and treatment of his ear condition were not in line with guidance in September and November 2022.

4. He also complains the Trust did not take appropriate action when the Provider discharged him from its service in November 2022. The impact of this was that he could not access the treatment he needed.

5. Mr E says the overall impact of what happened was that his symptoms worsened, with both ears now being affected. He could not return to work as a teacher, which has had a financial impact. The situation has had a profound effect on his life, affecting his ability to sleep, his wellbeing and his ability to socialise.

6. The outcomes he seeks are service improvements and a financial remedy in line with the Ombudsman’s guidance on financial remedy.

7. Mr E was referred by his GP in November 2021 to the Trust’s audiology department, as the GP understood him to have issues related to hearing loss. It appears the referral was rejected and Mr E was not notified of this. Mr E returned to his GP, who referred him to the Trust’s ear nose and throat (ENT) department in February 2022 in with tinnitus symptoms that were significantly impacting his daily life.

8. The Trust referred Mr E to the Provider, where he was reviewed in September 2022 by an ENT consultant. The consultant made three provisional diagnoses and referred Mr E to the Trust's audiology department.

9. The Provider carried out a further consultation in November 2022 and discharged Mr E from their service. Mr E says the Trust should have taken some action at this point, as he says he was discharged without full investigation, and without any diagnosis or treatment.

the Provider

13. The relevant guidance for patients presenting to ENT, with the symptoms outlined on the referral from the GP, are GMC Good Medical Practice (the guidance). We consider the actions of both organisations were in line with the guidance and will explain the reasons below.

14. the Provider carried out Mr E’s assessments. It appears from the records that this was NHS care outsourced by the Trust to a private provider. Our adviser explained this is common practice to reduce waiting lists.

15. In September the consultant from the Provider took a focused history (tinnitus, clicking, sinusitis, noise exposure), examined Mr E’s nose and ears, performed a nasoendoscopy (where a thin tube with a camera is passed through the nostril) and reviewed the MRI findings.

16. Our adviser told us this assessment was thorough and proportionate to the presenting problem. We consider this was in line with paragraphs 15 and 16 of the guidance which says:

‘You must adequately assess the patient’s condition, taking account of their history and their views, and examining the patient as appropriate.’

and ‘You must provide a good standard of practice and care.’

17. The consultant documented that the provisional diagnoses were discussed and that they had agreed to refer Mr E to audiology and arrange a CT. This demonstrated shared decisionmaking and responsiveness to Mr E’s concerns. This was in line with paragraph 32 of the guidance which says: ‘You must give patients the information they want or need in a way they can understand.’

18. The consultant arranged a CT scan and made a referral to audiology for tinnitus therapy and a stapedial reflex test (to check how the ear reacts to loud sounds). The records note the plan to call Mr E back with results in 12 weeks. These actions were in line with 15b and 15c of the guidance:

‘b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs.’

19. To summarise this consultation, the records show the consultant carried out the assessment in line with the guidance and made reasonable possible diagnoses, based on the information provided from the referral and the consultation. They provided continuity of care by arranging to see Mr E again once the test results were back.

20. We can see the follow up appointment was in November 2022. The records show this consultation was also in line with the guidance.

21. The consultant took a detailed history (tinnitus, clicking, sinusitis), performed otoscopy (an examination of the ear canal and eardrum using a handheld tool called an otoscope) and a nasoendoscopy, reviewed MRI and CT results, and interpreted the audiogram and stapedial reflexes. Our adviser told us this thorough assessment was in line with paragraph 15 of the guidance:

‘You must adequately assess the patient’s condition, taking account of their history, their views and values, and, where necessary, examining the patient.’

22. The consultant letter summarised the discussion with Mr E of a possible diagnosis of stapedial myoclonus. This is a rare form of tinnitus caused by contractions of a muscle in the middle ear.

23. Our adviser told us it was correct that the consultant discussed and considered this, and explained the management challenges of this condition. The adviser explained this is a rare condition and so it was reasonable that the consultant did not reach the definitive conclusion that this was the cause of Mr E’s symptoms.

24. The records show that the Provider made reasonable possible diagnoses, offered suggestions for management and then discharged Mr E. Our adviser told us that as there was no active intervention the consultant considered they could offer, this was a reasonable conclusion to the referral. There are no indications of failings in the way the organisation dealt with Mr E.

25. We can know Mr E was unhappy being discharged without a definite diagnosis or ongoing treatment plan. Our adviser explained that sadly it is sometimes the case that with a suspected rare condition the options offered do not meet the expectations of the patient. It is understandable that Mr E was left frustrated with his ongoing symptoms.

26. Our adviser told us the Provider did have the option to refer Mr E to an otologist (a specialised ENT surgeon that manages complex conditions), as he had unresolved symptoms. There is no guidance that says this must happen. Our adviser told us that as the tests showed there was an absence of any underlying pathology it was reasonable for the Provider to discharge Mr E back to the referrer.

27. The discharge letter informed the referrer (originally the GP) of the discharge and ensured the GP knew how to re-engage the service if required.

28. We looked to see if there was more the Trust should have done after the Provider discharged Mr E. The referral had been outsourced to the Provider by the Trust, having originally been made by the GP. For this reason it was reasonable that the Trust referred any concerns back to the Provider, and that the Provider sent the discharge letter to the referrer – the GP.

29. Our adviser said the Trust could have suggested the GP refer Mr E to a specialist otologist in a specialist centre if they had considered there were grounds to do this. As outlined in paragraph 26 there was no formal requirement for either organisation to do this.

30. We recognise Mr E’s frustration at being left with unresolved symptoms, and we are sorry this has been his experience. We have not identified that this is due to any indications of failings on the part of either organisation and so have decided there is no further action we need to take.

1. We have carefully considered Mr E’s complaints. We did not see any indications of failings in the investigations, diagnosis and treatment by the Provider, or in the subsequent actions of the Trust. For this reason we will not be taking further action.

2. We were sorry to hear about how much this experience affected Mr E. We hope our statement explains the reasons we have concluded there is no further action we need to take.