Guy's and St Thomas' NHS Foundation Trust

3. Ms E complains about aspects of the care and treatment she received from the Trust between November 2021 and September 2024.

4. Specifically, Ms E says the Trust: • did not prepare her properly before surgery, including not marking her up, and failed to make her breasts symmetrical after surgery on the 23 November 2021 • involved a second surgeon who she feels did not have sufficient experience to perform the surgery and did not properly close the incision during the procedure in November 2021 • did not respond to her complaint in an appropriate or adequate way.

5. Ms E says because of these failings her issues her breasts were left asymmetrical. She says the difference is noticeable even when she is wearing clothes. She says she did not receive a proper explanation of what went wrong during the surgery. She believes the second surgeon should not have performed the surgery on her left breast given their limited experience in breast reconstruction. She has needed six additional surgeries to address the outcome of the initial operation.

6. Additionally, she says the Trust’s response to her complaint was inaccurate, left her feeling disrespected, and further affected her mental health. She felt a lack of dignity and care in how she was treated by the Trust, particularly after being left vulnerable following her cancer treatment.

7. Ms E also expressed concerns her appearance influenced how she was treated by the Trust. She believes that assumptions were made about her not having future personal or professional prospects, because of her age, appearance, or perceived likelihood of forming relationships or having children. This has caused her significant emotional distress. Ms E worked in the fashion industry but has not returned to work because of her mental health, which she says was deeply affected by her experience.

8. Ms E is looking for financial remedy, service improvements, an explanation and an apology.

9. In September 2020, Ms E was diagnosed with breast cancer.

10. In February 2021, Ms E had a single mastectomy on one breast. This is a surgical procedure to remove a breast. The Trust informed Ms E further surgery would be required to make her breasts symmetrical. Around this time, she began radiotherapy.

11. In May 2021, Ms E attended the Trust. It told her, her non-cancerous breast would be operated on and she would have a mastectomy.

12. In October 2021, Ms E attended a further appointment at the Trust to discuss treatment options.

13. In November 2021, Ms E attended the Trust for the planned surgery on her non-cancerous breast.

14. The next day, the Trust discharged Ms E.

15. Four days later, Ms E returned to the Trust for a follow-up appointment with a different consultant. The Trust explained that the lead surgeon was unavailable for this appointment and advised her to allow time for her incisions and breasts to heal. During the appointment, it was discussed that she would require a wound debridement procedure. This is a procedure that removes dead, damaged, or infected tissue from a wound to support healing.

16. In early December 2021, Ms E attended the Trust for the wound debridement procedure. However, the procedure was not carried out. The Trust explained that her wound showed signs of dried blood and oozing, making her at high risk of infection. They decided to reschedule the procedure and informed her that her wound would need to be monitored closely in the meantime.

17. Between December 2021 and February 2022, Ms E attended the Trust for weekly appointments to monitor her wound’s healing progress. The wound healed very slowly, so the Trust used silver nitrate, an anti-infective treatment that prevents bacterial growth in wounds and helps them dry out and heal. By February 2022, her wound had fully healed.

18. In February 2022, after her wound had healed, Ms E requested further surgery to address the scar tissue. The Trust referred her for steroid injections.

19. Around March 2022, Ms E was scheduled for a second surgery. However, blood tests showed that her thyroid-stimulating hormone (TSH) levels were too high to proceed safely. The Trust prescribed carbimazole to treat the issue, and the Trust confirmed that the surgery would go ahead once her thyroid levels returned to normal.

20. Within two weeks, Ms E’s blood tests showed that her thyroid readings were normal. Ms E was placed on another surgeon’s waiting list.

21. Around April 2022, Ms E was referred to the Trust’s plastic surgery unit.

22. In September 2023, Ms E had corrective surgery. The Trust advised her that additional surgeries would be needed to make her breasts symmetrical. She was also informed that she might lose her nipple and require a skin graft. The Trust indicated that the waiting time for her next surgery would be approximately six months.

23. In December 2024, Ms E underwent a third surgery. This procedure was performed at a private hospital but was funded by the NHS. She was informed that further surgery would still be required.

24. In April 2025, Ms E had a fourth surgery, which also took place at the same private hospital.

25. Since then, Ms E has undergone two additional surgeries to address issues arising from the initial surgery in November 2021.

28. The law states a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Ms E to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to her.

29. We can see that Ms E became aware of the issues relating to her care and treatment in November 2021. This is when she had the surgery on her non-cancerous breast.

30. In order for her complaint to be within our 12-month time consideration, Ms E should have brought her complaint to us by November 2022, at the latest. Ms E brought her complaint to us in November 2025. The complaint is three years outside our time limit consideration.

31. We can see Ms E complained to the Trust in November 2022. This was within the 12 month time consideration.

32. Ms E said the reason for the delay in bringing her complaint to us was because after she received the Trust’s first response in April 2023, she believed the Trust would carry out the corrective surgery she needed sooner.

33. She also said she felt the Trust did not understand her complaint properly. She said she felt she needed to complain again to clarify and explain the issue. She hoped rephrasing her questions might lead to a different response. She also said she felt unclear about the next steps required.

34. She sent this further complaint to the Trust in June 2023. At this time, the Trust had already directed Ms E to us, if she wished to take her complaint further. It provided details on how to do this. We believe Ms E was aware of the next steps in the complaint process, at this time.

35. Ms E attended a local resolution meeting at the Trust in September 2024.

36. The Trust responded again in June 2024.

37. Ms E did not contact us after the Trust’s second response in June 2024. She said this was because she was taking antidepressant medication. She said at this time,felt unable to think clearly or take action.

38. Following the Trust’s final response in September 2024, Ms E explained that she delayed contacting us because her research led her to NHS Resolution. She submitted a claim to NHS Resolution as she believed they could provide an independent investigation of her concerns. Ms E felt that the Trust’s internal investigation might not be impartial and worried she may not have explained her complaint properly. By this time, the Trust had directed Ms E to us on several occasions.

39. Ms E received her NHS Resolution’s response in July 2025 but did not bring her complaint to us until November 2025. She said the four month delay was because she felt misunderstood and was struggling with her mental health. She said this meant she was unable to bring her complaint to us sooner.

40. From the evidence provided, we can see that Ms E first submitted her complaint to the Trust in November 2022. The Trust responded in April 2023 and advised her to come to us.

41. In June 2023, Ms E responded to the Trust, raising the same concerns as in her original complaint. She attended a local resolution meeting in September. In February 2024, Ms E submitted a further concern about how the Trust handled her complaint. The Trust responded to both her June 2023 and February 2024 complaints in June 2024 and, again, directed her to us.

42. In May 2024, Ms E received the Trust’s response following the local resolution meeting. She then returned to the Trust in September with the same concerns. The Trust responded at the end of September, providing what it called its final response, and again advised Ms E to bring her complaint to us.

43. This means local resolution process took one year and ten months to complete.

44. From the evidence we have seen, we understand Ms E contacted the Trust three times after making her initial complaint and raised the same concerns. In each response, the Trust signposted her to us and provided our contact details, explaining how she could escalate her concerns. Ms E also raised separate complaint about how the Trust handled her complaint. From the Trust responses, we are satisfied it addressed the concerns raised.

45. We understand that making a complaint was challenging for Ms E and impacted her mental health. We also recognised she felt the Trust was not fully understanding her issues and that returning to the Trust might lead to a different or better outcome. We have seen evidence to show the Trust clearly set out its position in its responses and signposted her to us multiple times, including April, June and September 2024.

46. While Ms E has said she experienced procrastination and poor mental health during this time, we can see that she continued to engage with the Trust and submitted complaints during this period.

47. Based on the information provided, we are not satisfied there are sufficient reasons to set aside our time limit for bringing a complaint to us. Therefore, we will not investigate this matter further.

48. We do recognise how difficult it can be to raise a complaint and we would like to thank Ms E for bringing her concerns to us.

1. We have carefully considered Ms E Complaint about Guy’s and St Thomas’ NHS Foundation Trust (the Trust). We were very sorry to hear about what happened to Ms E and the pain and distress it caused her.

2. Having reviewed the evidence, we have decided the complaint falls outside our time limit. We have decided there is no good reason for us to put out time limit aside.