King's College Hospital NHS Foundation Trust

3. Mr B complains about the care and treatment he received from the Trust in October and November 2024 when he had surgery to put a clip on a bulge in a blood vessel in his brain.

4. Mr B says the Trust:

• did not adequately assess his post-operative symptoms of confusion • lied about when his stroke happened • did not communicate properly with family after his surgery • lost his glasses • issued out of date documentation relating to surgery visiting rules.

5. Mr B says because of this experience, he may not regain his fine motor skills and has incurred costs such as paying for a cleaner and a gardener as he can no longer do this himself. Mr B also had to pay to replace his glasses which were lost while in hospital. He also said he lost an opportunity to have family members stay with him when he had his surgery, and he has lost faith in the Trust.

6. As an outcome to his complaint, Mr B would like to be re-imbursed for the cost of replacing his glasses, service improvements, and compensation to recognise his experience.

7. In late October 2024, Mr B attended a hospital at the Trust for elective right mini-craniotomy and clipping of recurrent communicating segment aneurysm. This means a small hole was made in the right side of the skull and a clip was put on a bulge that had returned in a blood vessel.

8. After surgery Mr B experienced some confusion and right sided weakness. Four days later, Mr B had a fall while recovering on a ward and a CT scan showed he had suffered a stroke.

9. While at the hospital, Mr B was transferred several times to different wards and his glasses were lost.

Did not adequately assess Mr B’s post-surgery symptoms

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

14. Mr B complains the Trust did not properly review the symptoms of confusion he was showing three days after surgery.

15. The NMC guidance says nurses must listen to people and respond to their concerns.

16. Mr B’s family had become concerned that Mr B was still showing signs of confusion after surgery and spoke to a member of the nursing staff about their concerns.

17. In line with the NMC guidance, the nurse acted upon the families concerns and used the Glasgow Coma Scale (GCS) to assess Mr B’s symptoms and called the family back to tell them, based on the assessment, Mr B was alert, oriented and not showing signs of acute confusion.

18. The NICE head injury guidelines explain that the GCS is a 3‑part scoring system that assesses a person’s level of consciousness by rating their eye opening (1–4), verbal response (1–5) and motor response (1–6), giving a total score between 3 and 15. The scores in each element of the GCS are totalled to give the overall GCS score, which ranges from 3 (unresponsive in all domains) to 15 (no deficits in responsiveness).

19. Mr B scored 15/15 on the GCS. According to NICE guidelines a score of 15 represents no deficits in responsiveness, indicating that he had returned to full consciousness and demonstrated appropriate neurological recovery following surgery.

20. Mr B was also reviewed by the on-call neurosurgical clinical fellow the same day who did not raise any concerns.

21. Our adviser told us the GCS is recognised internationally as the appropriate tool for assessing a person’s level of consciousness and basic neurological function. They said, although it focuses on a limited set of symptoms, in a neurological postoperative environment, where a patient is showing signs such as confusion, the GCS is the most suitable method for assessing their condition.

22. We consider the Trust did appropriately review Mr B’s symptoms of confusion in line with the NICE head injury guidelines, as such we have not seen any indications of failing for this aspect of the complaint.

The Trust lied about when Mr B’s stroke occurred

23. Mr B thinks his stroke occurred earlier than the Trust report as he was showing signs of confusion (such as thinking people had been to visit him when they had not) and had some left sided weakness after surgery.

24. When Mr B came out of neurosurgery, he was transferred directly to ICU which indicates he required close monitoring and a high level of postoperative support. Mr B had some left sided weakness, and his blood pressure was unstable.

25. Our adviser told us a stroke could have occurred during the operation, as this is a recognised risk of neurosurgery, but it is extremely difficult to assess this immediately. This is because the patient is still under the effects of anaesthesia, and clinicians often need several hours before a reliable neurological assessment can be made.

26. Our adviser explained that after brain surgery, symptoms such as onesided weakness and confusion are common and may be explained by postoperative brain oedema (brain swelling). This swelling typically takes a couple of days to settle. As the swelling reduces, the patient’s condition may appear to improve. Any underlying issue, such as a stroke, can become more apparent once the swelling subsides.

27. It is therefore very difficult to say whether Mr B’s stroke occurred prior to it being confirmed by CT scan five days after his surgery. Our adviser told us the only way to know precisely when the stroke occurred would have been through serial imaging beginning immediately after surgery, but that there was no clinical justification for that approach.

28. The GMC guidance says doctors should promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

29. Our adviser said there is no guidance that recommends routine or scheduled CT imaging following brain surgery. Instead, CT scans are done when specific clinical indications arise which our adviser said did not happen in Mr B’s case.

30. Therefore, we consider the Trust acted in line with the GMC guidance as there was no clinical reason for the Trust to have performed a CT scan earlier than it did.

31. We can see Mr B’s symptoms after surgery were very worrying for him and his family and that this caused a great deal of concern about when he might have had the stoke. The family have told us they feel he might have recovered better if he had been treated for a stroke earlier.

32. Unfortunately, it is not possible to determine the exact timing of Mr B’s stroke. However, we have not seen any evidence to suggest that the Trust should have conducted a scan earlier or that it lied about when the stroke occurred.

The Trust did not communicate properly with family after his surgery…i.e. when moving wards The Trust issued out of date documentation relating to surgery visiting rules

33. Mr B’s family complain they were often waiting hours for an update and were promised call backs from the Trust that never happened. They also complain that they were not always informed when he moved wards.

34. In its complaint response, the Trust have acknowledged there were delays in communication with Mr B’s family during his admission and have apologised for this.

35. Mr B’s family say these communication delays caused the family concern and inconvenience as they did not always know his condition or location within the hospital.

36. Our NHS Complaint standards say organisations should acknowledge when things go wrong and give meaningful apologies.

37. We can see that the Trust has already acknowledged a failing with its communication and apologised for this. This is in line with Our NHS Complaint Standards and as such we consider the Trust has already done enough to put right the injustice caused to Mr B and his family for this aspect of the complaint.

38. Before Mr B went into hospital the family were given a leaflet that informed them they would not be able to stay with Mr B while he waited for surgery. When the family dropped Mr B off at 7am they were told they could stay. The family told us they hadn’t made arrangements to be able to do that, and this meant family missed out on an opportunity to stay with Mr B. We understand this would have caused frustration and inconvenience.

39. In its complaint response, the Trust explained this was because visiting hours are between 12pm and 9pm, and Mr B was scheduled to be admitted at 7am. The Trust apologised for this miscommunication and explained sometimes compassionate exceptions can be made based on the individual needs of patients and their families.

40. We can see Mr B’s daughter was able to stay with him and wait while he had surgery. Therefore, we consider the injustice from this miscommunication was frustration and inconvenience at having to make other arrangements last minute.

41. We can see that the Trust has already acknowledged a failing with its miscommunication and apologised for this. This is in line with Our NHS Complaint Standards and as such we consider the Trust has already done enough to put right the injustice caused to Mr B and his family for this aspect of the complaint.

The Trust lost Mr B’s glasses

42. During Mr B’s time in hospital, his glasses went missing sometime after he had surgery and were last documented by the Trust on a property checklist 3 days after surgery.

43. In the complaint response, the Trust acknowledged that a property checklist was not completed upon his transfer to some of the wards. It apologised to Mr B for not completing the checklist and being unable to locate his glasses.

44. Our NHS Complaints Standards explain when things go wrong, we expect organisations to apologise and be ‘thorough and fair’ by ‘taking full accountability for mistakes identified’. They also say that organisations should identify suitable ways to put things right for people.

45. We consider the Trust has acted in line with our NHS complaints standards as it acknowledged the mistakes it made and apologised.

46. That said, as Mr B had to pay for new glasses to replace his lost ones, we felt the Trust needed to do more to recognise the inconvenience and financial impact this caused Mr B.

47. Therefore, we contacted the Trust and asked if it would consider reimbursing Mr B for his lost glasses. The Trust agreed to this and has agreed to pay Mr B £120.

48. We are satisfied the Trust has now ‘taken full accountability’ for the mistake it made and put it right. As such we consider this is appropriate to resolve this aspect of the complaint and will not be taking any further action.

49. We realise this is unlikely to be the overall outcome Mr B was looking for when he approached us. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it. We appreciate that this was a stressful and worrying experience for Mr B and his family and would like to thank him for bringing his concerns to our attention.

1. We have carefully considered Mr B’s complaint about King's College Hospital NHS Foundation Trust (the Trust). We recognise this was a deeply distressing time for Mr B and his family following major brain surgery, and that he continues to live with the lasting effects of his stroke.

2. We have seen an indication of a failing in how the Trust handled Mr B’s personal property, but we have not seen any indications of failings with the treatment provided to him. We have seen the Trust has already apologised for the mishandling of his glasses and has reimbursed him. As such, we consider the Trust has already done enough to remedy the impact of this, so we will take no further action. We explain this in more detail below.