University Hospitals Bristol and Weston NHS Foundation Trust

3. Mr O complains about the following treatment he received from the cardiology department at University Hospitals Bristol and Weston NHS Foundation Trust. Specifically, Mr O complains that:

• errors were made during a heart operation on 26 April 2023; he says two cuts were made into his heart instead of one and the ring attached to the mitral valve by the surgeon was too small. He also complains that his surgeon gave him contradictory information about what happened during his surgery.

• he was sexually assaulted during his ICU stay following the operation. He states staff repeatedly inserted a finger into his rectum without warning or seeking consent and he was exposed from the waist down during a hoisting without consent • staff’s attitude when Mr O self-discharged on 14 May 2023, due to a fear of remaining in hospital, was inappropriate and there was inadequate follow-up after his self-discharge • his discharge summary was inaccurate.

4. He says that due to the mistakes made during his surgery, he now suffers from severe mitral valve stenosis leading to breathlessness affecting his day-to-day activity. He is now unable to work due to breathlessness, which causes him severe stress due to his loss of earnings and inability to provide for his family. He also says that his mental health has been detrimentally affected, including experiencing suicidal idealisation and personality changes.

5. Mr O is seeking financial remedy and service improvements.

6. Mr O had been diagnosed with coronary artery disease (when heart’s blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries) and mitral regurgitation (condition where the mitral valve is not working correctly).

7. On 26 April 2023, surgeons at the Trust carried out heart surgery on Mr O, to repair his mitral valve and perform a coronary artery bypass graft. This is a surgical procedure to improve blood flow to the heart by creating a new route around narrowed or blocked coronary arteries.

8. During Mr O’s surgery, the mitral valve was repaired with an annuloplasty 30mm ring, which is a prosthetic device made of metal, plastic or mesh that is surgically sewn around a faulty heart valve.

9. Following Mr O’s surgery, he stayed in the Cardiac Intensive Care Unit until 10 May when he was discharged to a Specialist Cardiac Surgery Ward.

10. On 13 May, Mr O self-discharged from the hospital.

11. Later, Mr O experienced increasing symptoms of breathlessness and had further investigations. The cardiologist diagnosed severe mitral stenosis (narrowing of the heart’s mitral valve restricting blood flow) affecting the annuloplasty ring with associated marked exercise-induced pulmonary hypertension (a condition where blood pressure in the lung arteries rises abnormally during physical activity, despite being normal at rest). The cardiologist explained to Mr O that they could re-do the surgery to insert a mechanical ring (removal of damaged valve and replacement with mechanical valve).

16. Before we decide if we should investigate a complaint in more detail, we look at a few different factors. We consider whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. We also look at whether what happened had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.

17. If we think there was a failing, and that this had an impact that has not been put right, we will usually investigate in more detail.

Operation

18. Mr O complains that errors were made during a heart operation on 26 April 2023, including that two cuts were made his heart instead of one and that the ring attached to his mitral valve was too small. Mr O explained that his operation lasted seven and a half hours, and that he believes it took this long due to mistakes made during his surgery. He does not feel he has received a clear explanation on what happened during his surgery and why his surgery was so long. He told us that mistakes were made that have led to the ongoing health issues he has since experienced.

19. Mr O discussed this with the surgeon responsible for his operation and care (not the surgeons who carried out the operation) twice. The Trust explained that the surgeon answered Mr O’s questions regarding his surgery and showed Mr O his latest trans-oesophageal heart scan result and his heart functioning. It said that there were some complications during the surgery, and that there was a graft to the right side of the heart to aid function and that an intra-aortic balloon pump (support device to help the heart pump more blood) was inserted and then removed. It said that the surgeon discussed Mr O’s recovery with him.

20. We first address Mr O’s concern that two cuts were made into his heart. As we shall go on to explain, that is not what happened. Mr O suffered a rare, but recognised complication during his operation: a tear to one of the heart chambers.

21. Our adviser explained that during Mr O’s surgery, his mitral valve was approached through the left atrium, which is standard procedure. They told us that access to the valve was noted to be difficult and in exposing the valve a tear occurred in the right atrium, presumably during retraction. Retraction is the process of pulling back or holding aside tissue so the surgeon can access the area they need to operate on. They said that this caused a transient air lock (a temporary blockage of blood flow caused by a small bubble of air) in the bypass circuit (the temporary mechanical system diverting blood away from the heart to provide oxygenated blood to the body during surgery) for around four minutes.

22. We recognise that it must have been deeply concerning for Mr O to learn that his procedure took longer than expected and that there was a complication. We hope it is of some reassurance for him to know that the fact this happened does not necessarily mean something was done wrong. Our adviser told us that this is a known complication in cardiac surgery which teams are trained to deal with, and, importantly, that it was dealt with as they would expect.

23. Our adviser also told us that during Mr O’s surgery, there were issues with right ventricular dysfunction (the right ventricle not pumping as well as it should) and systolic anterior motion of the mitral valve (when part of the mitral valve moves the wrong way during contraction and can partially block blood flow leaving the heart). They said that again, these issues were both resolved by the surgeons appropriately, as they would expect.

24. Mr O says his wife was told by one of the surgeons after the operation that they could not access Mr O’s valve, so they made another cut on his heart. Mr O also told us that he was told by his responsible consultant surgeon (a different surgeon) that one of the sharp-edged instruments might have caused the cut when it was removed. We cannot comment on how accurate these reports are, as we do not have any evidence to support either claim of what was said. It might be that the surgeons gave incorrect information, or it might be that Mr O and his wife misunderstood what was said. Unfortunately, we cannot robustly conclude on the point ether way. It is understandable that hearing different accounts of what happened has confused and frustrated Mr O. We hope our account of what actually happened enables him to understand the events that took place during his operation and reassures him that though of course unfortunate, the complications were handled properly.

25. Turning next to the size of the ring used, our adviser explained that the ring chosen was used to support the mitral valve repair and restore the valve anulus (part of the mitral valve) to its normal dimensions and shape. They explained that a 30mm annuloplasty ring was within the range of ring sizes that would be expected to be used in a patient with Mr O’s body surface area. They said that the exact size of ring is determined during surgery by intraoperative measurements (physical tests) and assessments of the valve made under the direct vision of the surgeon during the surgery. They also explained that mitral stenosis can occur after an annuloplasty ring is implanted and is a recognised but rare complication. This means that it can happen, even when the right sized ring is used, as it was here.

26. We hope that this helps to assure Mr O and his wife that the surgeons acted how they were expected to during his surgery and did not make any mistakes.

Use of BMS

27. Mr O told us that staff sexually assaulted him during his intensive care unit (ICU) stay following the operation when they repeatedly inserted a finger into his rectum without explanation or seeking consent.

28. The Trust explained why and how the BMS was used.

29. It said these interventions can feel uncomfortable for the patient and can feel like they are having a rectal examination. The Trust also noted that three to four staff at a time are required during these procedures, due to the manual handling requirements of ventilated and sedated patients.

30. The Trust’s BMS Policy outlines that patients should be considered for BMS insertion if they have episodes of type 6 or 7 stools on at least three occasions with one or more of the following criteria: high risk of skin breakdown or skin damage to buttocks/perianal area, sacral pressure sore at risk from faecal contamination, or sacral burns at risk of infection. We consider that Mr O fit these criteria as our nursing adviser told us that the decision to insert a BMS was made following ongoing diarrhoea, to protect Mr O’s skin and avoid potential skin breakdown. We think it was, therefore, appropriate for a BMS to be used.

31. The policy outlines that a BMS can be inserted in the patient’s best interests if they are unable to consent. It is noted within Mr O’s medical records that on the day the BMS was inserted, he was heavily sedated at level 3 on the Glasgow Coma Scale (indicating complete unresponsiveness). Mr O therefore did not have capacity to give consent to the BMS and it appears to have been done in his best interest, in line with the policy.

32. The policy outlines that daily maintenance should take place, which can involve deflating and reinflating the BMS balloon, irrigating the BMS and re-positioning the BMS and faecal collection bag. Our adviser confirmed that these interventions took place. These are the actions that Mr O complains of and considers to amount to sexual assault. We hope we are able to reassure Mr O that the actions taken were necessary and appropriate. As we shall go on to explain, Mr O’s perception of the events in ICU, though real to him, is not accurate.

33. It is noted that Mr O was disorientated, confused, delirious and hallucinating at times during the period he had the BMS. This included seeing things at the end of his bed that were not really there.

34. Our nursing adviser told us that post-ICU hallucinations (also described as part of ICU delirium or post-intensive care syndrome) are common for patients to experience during or after an ICU stay. They said that these hallucinations can be vivid, distressing and sometimes remembered long after discharge. They told us that the Faculty of Intensive Care Medicine says that two thirds of the patients they see in follow-up clinics have experienced these hallucinations and that it is therefore unfortunately very common and normal. They said it would be very likely that what Mr O has perceived as sexual assault was the BMS being checked and flushed, as this can be a very uncomfortable experience.

35. This aligns with what the Trust’s Intensive Care Medicine consultant told Mr O about delirium, stating that it can happen due a combination of illness, medication, lack of sleep and the strange ICU environment. They explained that it can mean experiences feel real to a patient and that the patient may not be able to distinguish them from real events that occurred.

36. We appreciate that these memories feel real to Mr O and have absolutely no doubt as to how distressing he found his experience. We hope the information that we have outlined has given an explanation to why Mr O potentially has these memories and reassures him that, while clearly unpleasant, in reality, staff were trying to look after him appropriately and protect him from skin breakdown caused by the diarrhoea he was experiencing.

Hoisting

37. Mr O told us that whilst he was being hoisted, he was exposed from the waist down without consent, which was extremely distressing for him and his wife, who was present. He says that he was only covered up following his wife’s request.

38. The Trust explained that ideally staff should cover the patient with a sheet or pillowcase and apologised that it failed to provide the dignity Mr O deserved whilst being moved.

39. We do not doubt that this was an extremely unpleasant experience for Mr O and his wife. In line with our Complaint Standards, the Trust should have taken action to make sure any learning is identified and used to improve their services.

40. We asked the Trust to take further action on this part of Mr O’s complaint. In response, it has instructed the relevant teams to raise the importance of clear explanations of the hoisting procedure to patients and the maintenance of patient dignity during the procedure, at their safety briefings. It has also asked this to be raised at its next falls steering group, to highlight this learning point to wider audiences who will experience being hoisted.

41. We consider that in apologising and learning from this complaint, the Trust has taken appropriate actions to put things right in line with the Ombudsman’s Complaints Standards. Although nothing can change Mr O’s experience, we hope he feels reassured that this matter was taken seriously and that this should not happen again with patients in future.

Staff attitude to Mr O self-discharging

42. Mr O told us that on 13 May 2023 a member of staff at the Trust had a dismissive attitude when his wife explained that he wanted to self-discharge because he was too afraid to remain in hospital. Mr O says this was inappropriate and upsetting for him and his wife.

43. The Trust correctly explained that there was nothing in Mr O’s records documenting this conversation. It apologised that Mr O’s wife’s concerns were not met with compassion and that this was not in line with Trust values. It asked Mr O to provide the name of the doctor in question, so that it could investigate this complaint fully. The Trust did not investigate this further as it did not receive a name.

44. Unfortunately, there is no further evidence outlining the staff member’s dismissive attitude. This means we are regrettably unable to understand what happened and so have decided that there is no reasonable prospect of us making a fair, robust conclusion, even if we did investigate further. For this reason, we consider a formal investigation would not be practical for this complaint.

Follow-up after self-discharge

45. Mr O told us that he waited four months for a follow-up appointment after he self-discharged. He says given that he experienced significant complications during his stay in hospital and with the ongoing issues he experienced following the operation, he expected follow-up support sooner than four months. He says that if he had had a follow-up appointment sooner, his complications may not have been as severe, and his health would be better today.

46. The Trust explained that wait times for follow up post-surgery can vary, and that four months is not uncommon. It apologised that perhaps four months was too long post-discharge for the symptoms Mr O was experiencing. It said it planned to review its practice regarding patients who self-discharge.

47. We understand that Mr O was incredibly afraid to remain in hospital; Mr O’s wife has detailed the incredibly distressing day on which Mr O said he thought staff were trying to kill him and self-discharged. This was clearly an extremely difficult day for Mr O, his wife and their children.

48. We can see that after Mr O self-discharged without his medication on 13 May, he had a cardiac surgery outpatient clinic phone appointment on 6 July. The appointment notes that Mr O was not making a smooth recovery, and that Mr O’s GP should urgently follow up at the Trust with investigations. On 5 October, Mr O’s GP wrote to the cardiology department saying they had seen Mr O and requested an urgent review in clinic. Four days later, Mr O’s GP wrote to cardiology again to expedite their request for an urgent follow-up. On 23 October, Mr O then had a cardiac surgery outpatient clinic phone appointment where the clinical fellow booked him in for further in-person tests. We can see that there is a clinical note from the Cardiology department noting that Mr O’s referral for cardiac rehabilitation has been delayed due to the complex circumstances for Mr O’s discharge, which required ongoing input for Mr O.

49. It is unclear from the evidence we have reviewed whether Mr O’s GP did urgently follow up at the Trust for further investigations after the Trust’s cardiology team instructed them to in July. As Mr O had self-discharged from the hospital’s care, this meant that his GP had to refer Mr O back to the hospital to receive further care from the cardiology team. We cannot say exactly why Mr O experienced delays receiving in-person investigations, although it appears it may have been a result of the timing of the GP’s referral. Unfortunately, we can see that Mr O self-discharging contributed to the delay in him receiving in-person investigations, as he had to be referred back to the hospital.

50. Mr O had the right to self-discharge, and we do not underestimate the context of why he did. Unfortunately, this does not mean that this was the best clinical decision for his health following such a complex surgery. We are unfortunately unable to say whether Mr O’s follow-up and therefore general health would have been different if he had decided not to self-discharge.

Discharge summary

51. Mr O told us that his discharge summary from hospital was inaccurate; it said his operation was ‘uneventful’, which he says is untrue. Mr O told believes the Trust recorded his operation as ‘uneventful’ to hide failings that happened.

52. The Trust explained that ‘uneventful’ is a common clinical term used for surgery completed without complications. It said it understood this term might not reflect Mr O’s experience of care, so Mr O’s responsible consultant surgeon has sent follow up clinical letters outlining the details of the surgery to Mr O and his GP.

53. Our adviser explained that Mr O’s post-operative recovery was complex but consistent with what can be expected from this type of operation and the potential complications which can arise. Therefore, even if ‘uneventful’ is not – from a lay perspective – a term that seems quite right, we think it likely was clinically correct. The surgeons recorded the complications that arose elsewhere in Mr O’s records, and we hope this provides some reassurance that nobody was trying to hide anything.

54. We understand that it must have been confusing for Mr O to see the word ‘uneventful’ on his discharge summary, when he understood differently. The Trust has attempted to address this by organising for Mr O to meet his responsible consultant surgeon and sending Mr O’s GP a more detailed account of what their clinical view of Mr O is. We think this was a suitable way to address this complaint and hope our explanation provides him with some reassurance around the content of the letter.

1. We are sorry to learn of Mr O’s experiences with his Trust as well as the health issues he now experiences. We acknowledge that this has been an incredibly difficult time for Mr O and his family, as that his quality of life has deteriorated due to his health issues. There is no doubt that he suffered deep distress during his admission and his concerns about his care are entirely understandable. We hope our work can give him some reassurances regarding what happened to him and help him to move forward from his experience.

2. There are a number of reasons we will not be investigating this complaint any further. For the most part and particularly in relation to Mr O’s surgery and the staff use of the BMS, things did not go wrong. The surgeons acted how we would expect them to during Mr O’s surgery, and unfortunately complications can happen due to the complex nature of the surgery. We have shared information with Mr O surrounding the context of the use of the BMS. When things did go wrong, such as when Mr O was hoisted inappropriately, we think the Trust has taken action to put things right. We were unable to reach a robust view on one issue - staff attitude - because of a lack of evidence.