Epsom and St Helier University Hospitals NHS Trust

10. Mrs K complains about the care and treatment she received from the Trust between 18 November 2024 and 20 March 2025. Specifically, she complains that the Trust:

• incorrectly advised her to stop taking prednisolone after one week without tapering the dose • did not ensure appropriate communication and handover between staff when she was transferred between departments during her visit to the UTC • did not provide adequate information about how to collect her omeprazole prescription, resulting in a prolonged wait at the hospital pharmacy • did not adequately acknowledge these issues in its complaint response.

11. Mrs K says that stopping her steroid medication abruptly caused severe withdrawal symptoms including widespread pain, chills and significant discomfort.

12. She also says the lack of communication between staff during her attendance increased her anxiety and left her feeling confused and neglected.

13. Mrs K says the delay in collecting her omeprazole prescription also caused distress and contributed to worsening anxiety.

14. Mrs K says the overall experience has made her fearful of seeking urgent medical care in the future and has worsened her anxiety. She says she is now receiving mental health support.

15. Mrs K is seeking acknowledgement of the errors made in her care, a formal apology and financial compensation reflecting the distress she experienced.

16. Mrs K was diagnosed with ulcerative colitis in 2018. Ulcerative colitis is a long-term inflammatory bowel disease that causes inflammation and ulcers in the lining of the colon, which can lead to symptoms such as diarrhoea, abdominal pain and fatigue. Mrs K also has a history of anxiety.

17. On 18 November 2024, Mrs K attended the Trust’s urgent treatment centre (UTC) with symptoms suggesting a flare-up of her ulcerative colitis. A flare-up means a period where symptoms of the condition become worse.

18. During the visit to the UTC, Mrs K stated she experienced a lack of communication between staff when she was moved between different departments of the hospital. She reported being asked the same questions by different medical staff instead of providing adequate handovers between departments.

19. The records show that Mrs K was prescribed prednisolone, a corticosteroid medication used to reduce inflammation during ulcerative colitis flare-ups. She was prescribed 40mg of prednisolone daily for seven days.

20. Additionally, Mrs K was prescribed omeprazole, a medication to help reduce the amount of acid in the stomach.

21. When picking up the prescription Mrs K reported having to wait for hours to collect omeprazole. Mrs K said that staff did not inform her that she was able to collect the medication from a pharmacy outside the hospital or that she was able to purchase this over the counter.

22. Mrs K returned to the UTC for review on 25 November 2024. At this appointment she was advised to stop taking the steroid medication as her symptoms had improved.

23. On 26 November 2024, Mrs K reported experiencing symptoms she believed to be steroid withdrawal. She described feeling unexplained body pain, chills and overall discomfort.

24. On 27 November 2024, she was reviewed by a gastroenterologist (a specialist doctor who treats conditions affecting the digestive system). The gastroenterologist explained that she should not have suddenly stopped the steroid and restarted prednisolone at 35mg with a tapering plan, meaning the dose would be gradually reduced over time.

25. Mrs K later made a complaint to the Trust on 4 December 2024. The Trust issued its final complaint response on 20 March 2025.

26. Mrs K brought her complaint to us on 2 April 2025 because she remained dissatisfied with the Trust’s explanations.

31. When we look at a complaint, we first consider what are the relevant standards or guidelines to inform what should happen. Next, we go onto consider the version of events from all parties. We do so to identify if care fell so far below a standard to be considered a failing (often referred to as ‘maladministration’).

32. We recognise not all failings will be maladministration and some could be shortcomings that may not be failings. Where we identify this, we will make that distinction.

33. If we identify a failing, we consider the impact and injustice on the aggrieved, the scale of this and if we can link this to the failing. We refer to this as ‘flowing’ from the claimed injustice.

34. Following this we then look to establish what the organisation has done to put matters right for the failing (the ‘remedy’). We also note that not every failing will be maladministration. On occasions this could be a shortcoming. Where we identify so we will make this distinction in our decision making.

35. If we consider more could be done (or should be done), we may consider making a range of recommendations. Though we consider the individual circumstances of each complaint, it is for the Ombudsman to determine remedy that is fair, proportionate and reasonable.

Issue one - management of prednisolone treatment

36. Mrs K says she was incorrectly advised to stop taking 40mg of prednisolone after one week without tapering down the dose.

37. NICE guideline 130 states that oral corticosteroids are typically used as part of a time-limited course lasting approximately four to eight weeks, with the dose gradually reduced as symptoms improve. The guidance also recognises that treatment decisions should be based on clinical judgement and the severity of the patient’s flare, meaning that the exact duration of treatment may vary in individual cases and there is not a one size fits all rigid approach.

38. The Trust explained that when Mrs K attended the review appointment on 25 November 2024, she reported feeling much better, and the clinical team therefore considered that a short course of steroids had been sufficient. The Trust said Mrs K was advised to return if her symptoms worsened, at which point a longer tapering course of steroids could have been prescribed if required.

39. Our clinical adviser reviewed the medical records. From the advice sought we understand that some aspects of Mrs K’s presentation were reassuring as her physiological observations were stable, she did not have a fever, her inflammatory markers were only mildly elevated, and she reported that her symptoms were beginning to improve.

40. However, other features suggested the possibility of a more significant flare-up. These included her increased bowel frequency, the presence of anaemia and systemic symptoms such as joint pain.

41. NICE guideline 130 recommends that the severity of ulcerative colitis flares should be assessed using a recognised severity index, such as the Truelove and Witts Severity Index, to guide treatment decisions and determine whether specialist input is required.

42. The available records do not show that a formal severity assessment was completed using a recognised scoring system. In addition, factually we note that the records do not clearly document Mrs K’s baseline dose of maintenance aminosalicylate therapy, which are anti-inflammatory medications used to treat inflammatory bowel diseases such as ulcerative colitis.

43. Despite this, form the advice sought, we understand that prescribing an initial short course of oral steroids in the urgent care setting was not unreasonable or outside of the NICE guidance, particularly as Mrs K did not wish to be admitted and some aspects of her clinical presentation were reassuring.

44. However, we consider that the decision to stop the steroid after seven days was not appropriate, given the ongoing risk of relapse indicated by Mrs K’s symptoms.

45. NICE guideline 130 states that oral corticosteroids should usually be given as part of a time-limited course lasting several weeks, with gradual tapering. BNF states that corticosteroids may sometimes be stopped without tapering after short courses where the risk of relapse is low and the patient has not recently used steroids repeatedly or chronically.

46. Our adviser confirmed that stopping steroids after only seven days in a patient with features suggesting a higher risk of relapse would not be consistent with usual clinical practice. In line with this, we understand that in Mrs K’s case there were features indicating ongoing inflammatory disease activity and a risk of relapse, meaning that stopping treatment at this stage was unlikely to represent optimal management.

47. Taking all the available evidence into account, including the clinical advice we obtained, we consider that the decision to stop prednisolone after seven days without tapering was not fully in line with relevant clinical guidance, including NICE guidelines. This shows an indication of failing.

48. While we recognise that prescribing an initial short course of steroids was not unreasonable in the circumstances, the available evidence indicates that Mrs K remained at risk of relapse and further specialist input should likely have been sought at this stage.

49. The adviser also explained that the review appointment on 25 November 2024 provided a further opportunity to seek specialist gastroenterology advice, which would have been appropriate given the mixed clinical picture and the potential for more severe disease activity.

50. Mrs K says she experienced severe steroid withdrawal symptoms after stopping the medication. She reported unexplained pain throughout her body, chills and overall discomfort.

51. The Trust explained that when Mrs K was reviewed on 25 November 2024, she reported that her flare-up symptoms had improved, and therefore the clinical team considered that a short course of steroids was sufficient. The Trust said that steroids can be prescribed in two different ways: either as a high dose for a short course, or as a longer course with gradual tapering

52. The Trust says she was advised to stop taking the steroids and to re-attend if her symptoms returned, at which point a longer tapering course could have been prescribed if required. The Trust also explained that the medication packaging would have included a patient information leaflet containing guidance about the medication.

53. The BNF provides guidance on stopping corticosteroids. It explains that tapering is generally required where patients have received longer courses of corticosteroids or repeated steroid treatment, because abrupt cessation may lead to adrenal suppression or withdrawal symptoms.

54. However, the BNF states that tapering is not usually required after short courses of steroids, provided the patient has not recently received repeated or prolonged steroid therapy and the underlying condition is stable.

55. Our clinical adviser explained that steroid withdrawal symptoms are generally uncommon after a short seven-day course, particularly where the patient has not recently been taking corticosteroids repeatedly or long term. Withdrawal symptoms can include fever, muscle or joint pain, nasal inflammation, conjunctivitis, skin nodules and weight loss.

56. While some of the symptoms Mrs K reported could be consistent with steroid withdrawal, the adviser explained that it is more likely that clinically her symptoms represented a relapse of inflammatory symptoms associated with her ulcerative colitis, rather than specific response to a steroid withdrawal.

57. We are reassured that this is consistent with NICE guideline 130 which explains that patients experiencing flare-ups of ulcerative colitis may require a time-limited course of oral corticosteroids lasting several weeks, typically followed by a gradual reduction in dose once the flare-up has been controlled. Where steroid therapy is stopped prematurely in patients with ongoing inflammatory disease activity, there is an increased risk of inflammatory relapse.

58. The GMC’s Good Medical Practice guidance also states that doctors must prescribe treatment based on the best available evidence and recognised clinical guidance and should take appropriate steps to reduce the risk of harm to patients when making prescribing decisions.

59. From advice received we consider that the gastroenterologist’s decision on 27 November 2024 to restart prednisolone with a tapering schedule of reducing the dose by 5mg each week was clinically appropriate.

60. Taking all the evidence into account, including the Trust’s explanation and the independent clinical advice we obtained, we consider that Mrs K’s symptoms were more likely caused by a relapse of inflammatory disease activity after the steroid course was stopped, rather than steroid withdrawal itself.

61. We therefore found indications of a failing in the management of Mrs K’s steroid treatment, as the decision to stop prednisolone after seven days without tapering was not fully in line with relevant guidance.

62. When we find a failing, we then go onto establish if an impact and injustice can be linked to this. We often refer to this as ‘flowing’ from the failing.

63. We have then considered the impact of that failing. While this likely caused Mrs K avoidable discomfort, distress, and a short period of worsened symptoms before review on 27 November 2024, the evidence shows her treatment was promptly corrected by the gastroenterology team and no significant or lasting harm resulted.

64. Thus, we consider the severity was of one day from 26 November to the 27 November causing likely physiological and emotional upset.

65. We rely upon our severity of injustice scale to help inform our thinking on remedy as well as the NHS Complaint Standards which set out remedies should be proportionate to the injustice, fair and reasonable.

66. The Severity of Injustice Scale is a tool that contains six bandings of severity ranging from mild to moderate distress and pain. A case will generally be level one if we consider the person affected has experienced a low impact injustice such as annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We will usually consider an apology to be an appropriate remedy for these cases.

67. We also conduct checks on past complaints upheld and the types of remedy associated with them. To do this we conduct precedent checks into the organisation complained about to identify if there are wider systemic issues or emerging themes.

68. Lastly, we consider the individual circumstances of a complaint and the outcomes sought. We note by bringing her complaint to the Ombudsman, Mrs K is seeking acknowledgement of the errors made in her care, a formal apology and financial compensation reflecting the distress she experienced.

69. Through engaging with Mrs K to better understand her lived experience, we consider the injustice arising from this issue falls within the lower end of our Severity of Injustice Scale. This is because the impact was of short duration and did not result in any lasting clinical harm, although we recognise it caused avoidable discomfort, distress, and anxiety for a relatively short period.

70. We have also considered what the Trust has already done in response to Mrs K’s complaint. The Trust has provided explanations for the care given and has apologised for aspects of Mrs K’s experience, including delays and communication issues.

71. Taking all of this into account, we are satisfied that the Trust’s acknowledgement and apology represent an appropriate and proportionate remedy for the injustice identified. We do not consider that further investigation would achieve a different outcome or lead to a more meaningful remedy.

72. For these reasons, we do not see indications of unremedied injustice and do not consider this issue requires further investigation.

Issue two – communication and handover between departments

73. Mrs K says staff repeatedly asked her the same questions and there was inadequate communication between departments during her visit to the UTC.

74. The Trust stated that Mrs K was moved from the Emergency Department to the SDEC area once space became available because she was now under the care of the medical team.

75. The Trust also explained that it is common practice for clinicians to ask patients similar questions when they are transferred between teams, as this allows each clinician to independently confirm the patient’s medical history and symptoms.

76. It acknowledged that being moved between departments may have been unsettling for Mrs K and accepted that communication about her progress and the reasons for the moves was not good enough. It said staff should have kept her updated about the management plan and what to expect while she was under the care of different teams. The Trust confirmed this feedback had been provided to the relevant teams to support service improvement.

77. Our clinical adviser reviewed the handover documentation between departments. The adviser explained that the handover from the UTC to SDEC included some appropriate clinical information, including Mrs K’s presenting symptoms and initial assessment findings.

78. However, the adviser noted that the referral made to gastroenterology contained insufficient clinical detail. For example, it did not clearly record the dose of Mrs K’s maintenance aminosalicylate therapy, a formal assessment of the severity of her ulcerative colitis flare, or a detailed summary of the treatment already provided.

79. The GMC’s leadership and delegation guidance sets out expectations for safe communication and continuity of care. It states that when transferring care between professionals, doctors must ensure that relevant information about the patient’s condition, history and treatment is shared with the receiving team so that care can continue safely.

80. More specifically, the GMC’s leadership and delegation guidance states that when referring a patient to another service, clinicians must pass on:

• relevant information about the patient’s condition and history • the purpose of the referral • details of the investigation, care or treatment required.

81. Taking this into consideration, we understand that while the referral form itself was appropriate, the information recorded within it was incomplete and therefore did not fully meet the expectations set out in GMC leadership and delegation regarding safe referral and handover of care.

82. Providing comprehensive clinical information is particularly important in cases involving complex conditions such as inflammatory bowel disease, where specialist teams rely on accurate clinical details to prioritise referrals and determine urgency.

83. While the available evidence shows that Mrs K was subsequently reviewed by a gastroenterologist, the adviser explained that more detailed information in the referral could potentially have supported earlier specialist assessment.

84. Taking the available evidence into account, we consider that while Mrs K did receive ongoing clinical care during her attendance, the information included in the referral to gastroenterology did not fully meet the professional standards set out in GMC leadership and delegation for safe clinical handover and referral. However, Mrs K was subsequently reviewed by a gastroenterologist, and her treatment was amended shortly afterwards.

85. When we look at complaints, we recognise not all failings will be maladministration, that some may be shortcomings. In this instance we do not consider the information in the records demonstrates maladministration and could potentially be a shortcoming in human error.

86. We understand the period of time this went on for was relatively short, Mrs K presented to the emergency department at 10:47 am and left following medical consultant review at 21:30 pm – around eleven hours. Against our severity scale we would consider this to be a relatively low-level injustice sitting around level one on the severity scale.

87. We have not seen evidence that the shortcomings in the referral caused a material delay in treatment, altered the care Mrs K received, or led to a significant injustice requiring further investigation. We recognise though this would have been frustrating it is not a significant injustice on our severity scale and resides at level one. We consider the Trust’s acknowledgement of the issues identified, together with the learning it says has been taken from this case, represents an appropriate and proportionate remedy to the injustice described by Mrs K.

Issue three – advice regarding collection of omeprazole

88. Mrs K says she waited several hours at the hospital pharmacy to collect her omeprazole prescription.

89. Mrs K says she told staff she already had omeprazole at home and was not informed that she could obtain the medication from a community pharmacy or purchase it over the counter.

90. The Trust explained that both the UTC and SDEC areas normally hold pre-packaged supplies of omeprazole that can be provided directly to patients.

91. However, the Trust said that on some occasions stock may temporarily run out. The Trust explained that an alternative option would have been to issue a community prescription (FP10) that could be taken to an external pharmacy. The Trust said this option was eventually discussed with Mrs K, but she chose to return to the hospital pharmacy the following day instead.

92. It acknowledged that there was a delay before the option of issuing a community prescription was discussed with Mrs K and apologised for the inconvenience and impact this had on her condition. The Trust also said it had reflected on Mrs K’s feedback and confirmed that, going forward, the outpatient pharmacy team would offer patients the option of purchasing omeprazole directly where appropriate and provide approximate price information where possible.

93. When reviewing the records, our adviser confirmed that there is no documentation indicating that advice was given about alternative ways of obtaining omeprazole, such as purchasing it over the counter or collecting it from a community pharmacy.

94. The GMC’s good medical practice guidance states that doctors must ensure patients are provided with the information they need to make decisions about their care and treatment. This includes clear communication about medications, including how and where they can obtain prescribed medicines.

95. It also requires that important information and advice given to patients should be appropriately recorded in the medical notes, so that there is a clear record of the information provided and to support continuity of care.

96. While the absence of documentation does not necessarily mean that the advice was not given, the lack of a recorded discussion means we cannot confirm that Mrs K was clearly informed about alternative options for obtaining the medication.

97. We also recognise that omeprazole is widely available from community pharmacies without prescription. Clear advice about this option may have helped Mrs K avoid the delay she experienced while waiting for the hospital pharmacy.

98. Taking the available evidence into account, we are unable to conclude on the balance of probabilities that the Trust failed to provide appropriate advice about obtaining omeprazole. This is because there is no clear documentary evidence showing whether that discussion did or did not take place.

99. However, we recognise Mrs K experienced frustration and inconvenience due to the delay in obtaining the medication. The Trust has acknowledged this and apologised. In the circumstances, we do not consider there is sufficient evidence of a service failing causing unremedied injustice requiring further investigation.

100. Taking all the available evidence into account, we are unable to conclude on the balance of probabilities that the Trust failed to provide appropriate advice about obtaining omeprazole, as there is no clear documentary evidence confirming whether this discussion took place. However, we recognise that Mrs K experienced frustration and inconvenience due to the delay in obtaining her medication, which appears to have been of relatively short duration and limited to the day of her attendance.

101. We have considered this impact in line with our Severity of Injustice Scale and consider it falls within level one, as it relates to a one-off incident causing short-term inconvenience and distress without wider or lasting effects. We also note that the Trust has acknowledged this delay, apologised for the impact on Mrs K, and identified learning to improve how options are communicated to patients in future.

102. Taking all of this into account, we are satisfied that the Trust’s response represents an appropriate and proportionate remedy and there are no indications of unremedied injustice, we do not consider further investigation would be likely to achieve a different outcome.

Issue four – complaint handling

103. Mrs K says the Trust’s complaint response did not adequately acknowledge the errors in her care or the impact the events had on her mental health.

104. The Trust issued its final complaint response on 20 March 2025. In its response, the Trust set out the steps taken to investigate the complaint and provided explanations from several clinicians involved in Mrs K’s care, including the Consultant in Emergency Medicine, the Clinical Lead in Acute Medicine and the Medication Safety Officer.

105. The Trust acknowledged that communication during Mrs K’s attendance could have been better and apologised for the distress caused by delays in providing her medication. The Trust also explained the reasoning behind the decision to prescribe a short course of steroids and advised that Mrs K had been told to return if her symptoms worsened.

106. We assessed the Trust’s complaint handling against our Complaint Standards. These standards say that organisations should:

• carry out a fair and proportionate investigation of the complaint • provide clear and accurate explanations of what happened • acknowledge mistakes where they occur • recognise the impact of the events on the person affected • demonstrate learning or improvement where appropriate.

107. The Trust’s response provided a detailed explanation of Mrs K’s care and included comments from several clinicians involved in the investigation. It also acknowledged that aspects of communication during her attendance could have been improved.

108. However, we recognise that Mrs K feels the Trust’s response did not fully acknowledge the concerns she raised about the management of her steroid treatment or the impact the experience had on her wellbeing.

109. In particular, the Trust’s response largely focused on explaining the clinical reasoning behind the treatment decisions that were made, rather than clearly addressing whether aspects of care may not have been fully in line with relevant clinical guidance.

110. The NHS Complaint Standards emphasise the importance of recognising the personal impact of events and ensuring that complainants feel their concerns have been listened to and understood. While the Trust apologised for elements of Mrs K’s experience, we understand why she may feel that the response did not fully acknowledge the distress and anxiety she describes experiencing.

111. We also note that Mrs K reports that the events have affected her confidence in seeking urgent medical care and have worsened her anxiety, leading her to seek mental health support.

112. While the Trust provided explanations for the care she received and described some learning points regarding communication and medication supply processes, it is understandable that Mrs K may feel the response focused more on explaining the actions taken rather than fully recognising the overall impact the events had on her.

113. Taking this into account, we recognise why Mrs K may feel her concerns were not fully recognised through the complaint process. While the Trust’s response could have more clearly acknowledged the personal impact of events and aspects of care that were not fully in line with guidance, it did investigate the complaint, provided detailed explanations, and apologised for delays in obtaining medication.

114. We therefore consider this was a shortcoming in the way the complaint was responded to, rather than a significant failing in complaint handling that caused an unremedied injustice.

Conclusion

115. We recognise that this experience has been distressing for Mrs K, particularly given the impact it had on her anxiety and confidence in seeking urgent medical care.

116. We found that some aspects of Mrs K’s care were not fully in line with relevant guidance, particularly the decision to stop prednisolone after seven days without tapering and shortcomings in the information included within the referral to gastroenterology.

117. We are satisfied that these matters did not cause significant or lasting clinical harm. The evidence shows Mrs K was reviewed shortly afterwards by a gastroenterologist, and her treatment was promptly corrected with an appropriate tapering plan.

118. We also recognise the distress, inconvenience, and frustration Mrs K experienced, including the delay in obtaining medication and her dissatisfaction with the complaint response.

119. Taking all the evidence into account, we do not consider the failings identified are of a level that would justify a full investigation and that the Trust’s actions have done enough to put things right.

120. For these reasons, we will not investigate this complaint further.

121. We hope this explanation helps Mrs K understand how we reached our decision.

1. We have carefully considered Mrs K’s complaint about the care and treatment she received from Epsom and St Helier University Hospitals NHS Trust (the Trust) between 18 November 2024 and 20 March 2025.

2. Mrs K says the Trust did not manage her steroid treatment safely following a flare-up of her ulcerative colitis, and that there were failures in communication during her Urgent Treatment Centre (UTC) visit and in the advice given about collecting her medication.

3. We are sorry to learn of Mrs K’s concerns and recognise how distressing this experience has been for her.

4. Regarding the lack of tapering of a dose, we saw indications of failing but consider some of the claimed impact does not flow. We consider the Trust’s apology is fair, reasonable and proportionate remedy and therefore take no further action on this.

5. On the matter of appropriate communication –we identified a short coming that is not necessarily indicative of maladministration failing and consider an apology is sufficient remedy for the short duration this occurred in.

6. Relating to the complaint point of adequate information about how to collect her omeprazole prescription, resulting in a prolonged wait at the hospital pharmacy we have not identified this to be a severity of a lasting significance or hight impact. We understand the frustrations experienced and where we have reached a view on this matter we conclude enough has been done to remedy the failing.

7. Lastly on the issue of complaint handling, we consider there are indications of shortcomings here but not maladministration. Therefore, we take no further action.

8. We want to reassure Mrs K that we have looked carefully at all the available information. While we have identified some aspects of care that were not fully in line with relevant clinical guidance, we have not seen evidence that these issues caused significant or lasting harm.

9. We hope our explanation below helps Mrs K understand how we reached our view.