Salisbury NHS Foundation Trust

6. Mr P complains that on 9 April 2025 staff at the Trust failed to appropriately monitor him passing urine, and did not listen or act upon his concerns about the reduced volume of urine he was passing following his surgery.

7. Mr P states that, as a result, staff at the Trust discharged him prematurely, which delayed recognising and treating his urinary retention. He says this led to a worsening of his condition, him developing further complications and a deterioration in his health. He also states this delayed his subsequent cancer treatment and hindered his recovery.

8. Mr P also complains that he was provided with a cheese sandwich following his procedure which he believes was not appropriate. Mr P explains this made him feel like a nuisance and caused him distress.

9. As an outcome to this complaint Mr P seeks service improvements to the surgical day unit and financial remedy for his pain and suffering.

10. On the morning of 9 April 2025 Mr P, who is in his eighties, attended the surgical day unit at the Trust, for a planned day case procedure for a panendoscopy (test to have a closer look at the inside of his nose, voice box and food pipe), tonsillectomy (a procedure to remove tonsils) and to take biopsies from the tonsils and right tongue base.

11. Following the procedure doctors discharged Mr P and he returned home on the evening of 9 April.

12. Mr P attended the Emergency Department on the morning of 10 April having only passed a small amount of urine following his procedure the previous day. He was treated for post-operative urinary retention. He was catheterised and discharged for follow up care in the community.

13. Mr P again attended the Emergency Department on 13 April with severe pain, urinary retention with minimal drainage from his catheter and weakness. Mr P, was admitted and remained in hospital to manage his retention and other health conditions he had gone on to develop, including sepsis and pneumonia.

Urinary retention

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. Having done this, we saw no evidence that Mr P raised concerns with staff about his urinary output. Therefore, we cannot say staff should have acted on those concerns. We also consider that there was no requirement for staff to closely monitor his urinary output.

17. Mr P told us that following his procedure on 9 April that staff did not monitor him passing urine or respond to his concerns about this. He said that as a result, they discharged him prematurely that evening, which left his urinary retention undetected. He believed proper monitoring and listening to his concerns after the procedure could have prevented the eventual severity of his condition.

18. The Trust explained that passing urine following surgery is a standard check and all patients are required to pass urine prior to leaving hospital. It stated that there are several entries in the medical records about Mr P passing urine following the surgery and that he signed the discharge checklist confirming this. The Trust noted that there is no documentation regarding concerns raised by Mr P.

19. Guidelines for day-case surgery 2019 is applicable in this scenario. This says that voiding (passing urine) is not always required to discharge day surgical patients. It does note that it is important to identify patients who are at risk of developing later problems, such as those who have experienced prolonged instrumentation or manipulation of the bladder, which Mr P did not. This means that it was not absolutely necessary for staff to have checked that Mr P had passed urine before discharging him, but it is clear from the Trust’s response that it does expect staff to check this as standard, regardless.

20. The medical records indicate Mr P was observed by staff post operatively. There are two entries within the notes to say that he passed urine. There is a handwritten note stating that he walked to the toilet and passed urine, and a typed note saying that he passed urine comfortably.

21. We think there is enough evidence to show that Mr P did pass urine after his procedure and this was monitored and observed by staff on the unit.

22. We next looked at Mr P’s complaint that staff did not listen to his concerns about the volume of urine he passed. We recognise there is limited information in the medical records about the volume of urine he passed. We do not, however, consider this to be crucial, as we have already explained it was not essential for Mr P to pass urine, which in turn means there was no requirement for staff to monitor this. They should, however, have listened to any concerns he raised and acted upon them, as required.

23. Mr P’s medical notes do not record that he raised concerns. We do not know, even on the balance of probabilities, if this is because he did not raise any concerns, or because he raised concerns, but staff failed to document them. The notes do include a discharge form signed by Mr P, that is ticked that he passed urine. But again, there is no mention that he raised concerns when asked about this.

24. Because there is no documentation to show what concerns, if any, he raised, it is not possible for us to comment fairly and meaningfully on what staff should have done in this scenario. It may be that they would have taken different action, or they may have discharged him anyway, but with further advice on monitoring his urine output. Regrettably, we cannot reach a robust decision on this point.

25. It was incredibly unfortunate that Mr P went on to develop urinary retention, and we understand his prolonged period in hospital was a distressing time for both him and Mrs P. We think staff were right to check he’d passed urine, without monitoring the amount, and therefore do not consider that anything went wrong in that respect that might have prevented subsequent events. It is, of course, unfortunate that we could not reach a decision on the concerns he says he raised.

Cheese sandwich

26. Before we decide if we should investigate a complaint in more detail, we also look at whether what happened had a significant negative impact on the person in question. We prioritise the most severe complaints that will make the most impact on public services. Whilst we recognise that Mr P was upset by being offered the cheese sandwich, we are not satisfied that the impact described by Mr P, is significant enough for us to justify an investigation, or that doing so would lead to a meaningful outcome. We have therefore decided not to take this part of his complaint further.

27. Mr P told us he was offered a cheese sandwich following his procedure, which he feels was not appropriate given the type of surgery he had. Mr P explained that being given something he felt unable to eat, left him feeling as though he was not being cared for. We acknowledge that Mr P felt let down by being offered a sandwich that he did not feel able to eat.

28. We do not think that this has had a significant or lasting effect on him. Mr P told us he chose not to eat the sandwich and therefore did not experience any pain or discomfort as a result. Whilst we recognise this was upsetting at the time and part of his overall dissatisfaction with his care, the impact appears to be minimal and short lived.

29. In view of this, we do not consider it is proportionate to continue investigating this aspect of Mr P’s complaint, as it is not where our involvement would add the most value or have the greatest potential to improve public services. This does not minimise the impact the event had on Mr P and we are sorry to hear of the upset this caused him.

1. We have carefully considered Mr P’s complaint about Salisbury NHS Foundation Trust (the Trust).

2. We understand that Mr P was concerned that his aftercare following his surgery felt different from what he had previously experienced. We fully acknowledge why this, together with the complications he faced, led him to question the care he received.

3. We must, however, consider the actions of staff at the time, in the correct setting, without relying on hindsight of what Mr P sadly went on to experience. Having done this, we are satisfied that staff acted in line with relevant guidelines for day case surgeries, in how they monitored Mr P’s passing urine following his procedure.

4. We have also decided not to progress Mr P’s complaint regarding the cheese sandwich he was given by staff following his surgery.

5. We have gone on to explain our decision below.