Royal Devon University Healthcare NHS Foundation Trust

6. Miss Y complains that between May and June 2024 Royal Devon University Healthcare NHS Foundation Trust did not accept a referral and offer an urgent ENT appointment for her son because they were awaiting audiology investigations which were to take place the next day. She complains the Trust also did not explain why a second referral was rejected and did not provide them with advice and support or tell them that the second referral had been rejected.

7. Miss Y says this has been a very difficult time for the family and her son has suffered for a long time with pain and hearing loss which has also impacted his speech and development. She is seeking service improvements and financial remedy.

8. Miss Y’s son suffered from ear infections in 2024. He was treated with antibiotics. On some occasions he required admissions to hospital. His GP referred him to Paediatrics for immunity testing. He was diagnosed with glue ear. His GP was concerned this was causing him hearing problems and speech delay, so they referred him to Audiology in February where some of his responses to tests were outside normal limits. Audiology planned to repeat the test in three months’ time.

9. On the 29 May a Paediatrician reviewed Miss Y’s son and suggested immunity blood testing and made a referral to ENT. Her son attended a second Audiology appointment on 30 May which showed fluid in both of his middle ears. Results indicated a mild-to-moderate hearing loss, and his parents were advised to think about whether they wanted hearing aids for him due to his level of hearing loss, they also suggested a referral to ENT and Miss Y advised the Paediatrician had already made a referral.

10. Miss Y contacted ENT bookings a few days later to find out how long the waiting list to be seen was and was told it was several months. She asked if her son’s referral from the Paediatrician had been received and was told that the referral had been declined. She says she was told this was because they had an outstanding Audiology appointment. She says she was told to go back to their GP and start the process again.

11. Miss Y contacted Audiology and explained what had happened and it made a new referral. A week or so later she called ENT bookings again to ensure his referral had been received. She says ENT said the referral had been declined and advised to ‘offer advice and support’.

12. Miss Y told us she sought a private consultation as her son had suffered with over 18 ear infections by this point and had 18 courses of antibiotics. She was also concerned about his hearing, his speech, the antibiotic use, the systemic effect on his body and any long-term effects to his ears. Miss Y’s son saw an ENT specialist on 14 July, within a week. Miss Y said they told her they were very concerned about the amount of infections he had suffered and the challenges they had in being reviewed by the Trust’s ENT team. She said they advised he needed urgent bilateral grommet insertion surgery and exploration of his ear to ensure there was no long-term scarring.

13. The private clinician made a referral to an NHS ENT colleague at another Trust. Miss Y’s son had an appointment with them on 10 August, and he had his surgery on 9 September.

15. 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.

16. Miss Y told us she was concerned that the Trust did not accept the referral on 29 May or offer an urgent ENT appointment for her son because they were awaiting audiology investigations which were to take place the next day. She told us her son had been suffering from ear infections which was causing him pain and affecting his hearing and had been diagnosed as glue ear.

17. The Cochran Library which is a trusted online collection of high‑quality medical research and brings together studies that have been carefully reviewed, explains that glue ear (otitis media with effusion OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. It may cause hearing loss which, when persistent, may lead to developmental delay, social difficulty and poor quality of life. Management includes watchful waiting, auto inflation, medical and surgical treatment. Insertion of ventilation tubes (grommets) has often been used as the preferred treatment. Our adviser explained otitis media does not in itself have any urgency for surgical intervention.

18. NICE guidance on recurrent acute otitis media management says: • refer urgently (within two weeks) to an ENT specialist if nasopharyngeal cancer (rare) is suspected • consider referral to an ENT specialist for all people with recurrent OME, especially if the person has a craniofacial abnormality (Down's syndrome or a cleft palate), or recurrent episodes are unexplained, very distressing, or associated with complications • if referral is not necessary manage acute episodes in the same way as for initial presentation.

19. Based on the evidence we have seen it appears the Trust made a referral to ENT on 29 May after reviewing Miss Y’s son. This referral noted he was being seen in Audiology the following day. This action appears to be in line with the above NICE guidance, although the guidance does also say acute episodes can continue to be managed without this referral.

20. Miss Y told us she contacted ENT bookings a few days later to find out how long the waiting list to be seen was and was told it was several months. She said she asked if her son’s referral had been received and was told that the referral had been declined. She says she was told this was because her son had an outstanding audiology appointment. She says she was told to go back to their GP and start the process again.

21. In its complaint response in December 2024 the Trust explained this ENT referral was declined due to insufficient clinical detail in the referral and because Miss Y’s son was already under audiology care. It said the consultant advised them to wait for the next audiology appointment before proceeding.

22. The Trust explained the criteria for an ENT referral to be accepted is five or more documented episodes of OME in the same ear within the previous 12 months. However, the referral information for Miss Y’s son did not clearly meet these criteria. It said the referral said he had four ear infections since November and eight before this but did not specify if this was in one or both ears or which ear was affected.

23. This indicates that the information in the referral itself was not enough for the referral to meet the criteria to be accepted. Rather than the ENT Team getting this wrong.

24. However, the Trust has acknowledged the Paediatric Team referral lacked detail and had the referral detailed his medical history more clearly there would have been a high probability it would have been accepted at the end of May. The Trust also acknowledged there was no joined up thinking when the ENT referral was triaged, and his audiology appointment was within the next 24 hours. It said there could have been improved collaboration and pathway management across both specialities and recognised that had the referral been paused a different decision may have been made.

25. The Trust also acknowledged the family was not informed of the referral rejection, and this was an oversight caused by staffing pressures.

26. Miss Y also complains the Trust did not explain why the second referral by Audiology was rejected by ENT and did not provide them with advice and support or tell them that the second referral had been rejected. She told us she contacted Audiology and explained what had happened with the first referral being rejected, and it made a new referral in early June.

27. She said a week or so later she called ENT bookings again to ensure his referral had been received. She says ENT told her the referral had been declined a second time and advice had been given to offer advice and support to the family. She explained she felt she had to seek a private appointment and when they saw the specialist they advised her son needed urgent surgery as they were very concerned.

28. In its complaint response in December 2024 the Trust said it had no evidence of a second ENT referral being received and then rejected by the Trust. The Trust gave some possibilities to what happened about this referral, but it was unable to say what happened.

29. The Trust went on to explain that following the referral from the private clinician, ENT saw Miss Y’s son in July, and he underwent surgery in September. It explained his condition was not assessed to need urgent surgery and was routine. The Trust advised as Miss Y had not provided evidence from the private clinician so it could not comment on whether they viewed his condition as urgent or why.

30. In its second response the Trust also explained it has an ‘advice and guidance’ option so that the Triage Team can feedback to the referring Team. It explained therefore when Miss Y called ENT after the second referral when she was told about advice and support for the family, this was a mistake and what was being read to her was actually not intended to be instructions for feedback to the family. The Trust recognised there was no process for escalation of concerns by patients/parents with the booking Teams and no records of Miss Y’s contact with them.

31. The Trust went on to explain that although the surgery Miss Y’s son had not been noted as urgent when he was listed for this in July, he was placed at level P2. It said this means surgery to be offered in under 1 month which gives the impression of some urgency in him needing treatment.

32. Our Principles say when something has gone wrong, we expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. We also expect organisations to take action to learn and improve from mistakes.

33. Miss Y told us this has been a very difficult time for the family, and her son has suffered for a long time with pain and hearing loss which has also impacted his speech and development. She said she sought a private consultation as her son had suffered with over 18 ear infections by this point and had 18 courses of antibiotics. She was also concerned about his hearing, his speech, the antibiotic use, the systemic effect on his body and any long-term effects to his ears. Miss Y told us she was not reassured the Trust, had learned lessons and was going to make the service improvements it told her about.

34. We can see from what she told us this was a distressing, stressful and frustrating time for the family. We looked at what we saw had gone wrong and then looked at what impact we would be able to link directly to what went wrong.

35. We have seen that the period of time between when the first referral was made on 29 May and when he was seen privately by an ENT specialist in July was a month and a half. He then had another appointment with an NHS ENT specialist on 10 August. Therefore, based on the time it took for ENT at the Trust to see Miss Y’s son following the private referral, it appears the wait time to be seen was approximately six weeks. Had the referral on the 29 May been accepted by ENT at the Trust, on the balance of probability, it appears he would have been seen by the team at the end of June at the earliest, a month later. So, the delay experienced from what we saw went wrong was a month and a half.

36. The NHS Devon policy on Myringotomy/grommets for the management of OME in children under 12 years says it will only be funded if the child has persistent OME with documented hearing loss on 2 occasions assessed at intervals of 3 months or more* AND the child suffers from persistent: • bilateral OME with a hearing level in the better ear >20 dBHL confirmed over three months • unilateral OME with a hearing level in the better ear >20 dBHL confirmed over three months AND the impact of the hearing loss on a child’s developmental, social, or educational status is judged to be significant.

37. The above guidance supports that the decision to have surgery would not have been made until after the appointment with Audiology on 30 May. Our adviser agreed that this was in line with the above NICE guidelines and at this point there was no urgent criteria met for a more urgent referral and appointment.

38. This means we cannot say the delay we saw of a month and a half, led to 18 courses of antibiotics, and impacted directly on his hearing, speech and the systemic effect on his body and any long-term effects to his ears. We can clearly see it caused Miss Y concern about these matters. Especially given the private specialist told her they were very concerned about the amount of infections he had suffered and advised he needed urgent surgery and exploration of his ear to ensure there was no long-term scarring.

39. When we see an Organisation got something wrong and can see the impact this had, we look at our severity of injustice scale to decide the level of action needed to address this. This is a transparent scale the Ombudsman uses to ensure fairness in our decision making. We look at any complaints we have investigated regarding the organisation to look for any similar failings and remedies recommended. We also look at previous investigations with similar impacts to ensure our remedies are consistent with others to ensure fairness.

40. We looked at the impact Miss Y told us about, but just in relation to the failings we found. We also look at what the complainant has told us they are seeking to address their complaint. Miss Y told us she would like service improvements and financial remedy.

41. As we have explained above, we have seen the Trust caused a delay of a month and a half in Miss Y’s son being seen by an ENT specialist which led to a delay of a month and a half in surgery. As the surgery was not an emergency surgery it does not appear this wait would have caused the impacts Miss Y told us about in relation to 18 courses of antibiotics, and impacted directly on his hearing, speech and the systemic effect on his body and any long-term effects to his ears. We can see it caused concern and distress for Miss Y and her family.

42. Miss Y paid for an appointment with a private ENT specialist as she felt she had no other choice because she thought the Trust had declined two referrals. We have seen that Miss Y was clearly contacting the Trust and different departments dealing with her son’s investigations. She contacted the ENT Bookings Team twice and spoke with Audiology and was given information which caused confusion. We have seen that when she first called the ENT Bookings Team about the first referral she was advised to go back to her GP for a referral.

43. We would only consider asking an Organisation to reimburse private care and treatment costs if there was no other choice than to pay for this. We have seen Miss Y could have contacted her GP as advised for another referral or could have gone back to Audiology when she thought the referral had been declined again. It appears instead of doing this after a second telephone call she decided not to pursue this further through the NHS.

44. The Trust apologised for the lack of detail in the Paediatric referral. It also apologised for there being no joined up thinking and said it would take learning back to the Paediatric Team about the lack of detail and both Teams to see if better processes could be embedded to strengthen pathway oversight that are so closely linked. The Trust also apologised for any confusion caused by the information it gave Miss Y when she called the ENT bookings team on both occasions. The Trust apologised for the wording used in the first response in relation to the urgency of Miss Y’s son needing treatment.

45. It also explained it had reviewed its administrative processes and has put monitoring in place to improve communication following the family not being advised of the referral being declined. In its second complaint response the Trust explained it is the responsibility of the referrer to feedback to the patient/parent that the referral has been declined. It said it would feed this back to the Paediatrics Team.

46. We have seen the Trust made errors in referring Miss Y’s son and this caused a short delay in getting him onto the surgical list along with frustration and stress over the information the Trust gave about this. We are satisfied that this impact is at level two of our Severity of Injustice scale. This level is when what has gone wrong has had a relatively low impact which will often result in a degree of distress, inconvenience or minor pain. This could also include instances where an injustice was more serious but only took place one time or was for a short duration.

47. Due to the unprecedented pressures to our service following the Covid pandemic people have been waiting far longer than usual for us to look at their complaint. To address this, we have decided to focus on the more serious complaints that people bring to us, where they may have faced a big impact. For example, these may be about a potentially avoidable death or where someone has suffered prolonged pain. These types of complaints are where we can often make the biggest difference.

48. This means we are not looking further into complaints where we can see there has been a smaller impact. We have explained above why we think the impact Miss Y has told us about that can be linked to what went wrong falls into a lower level of impact on our severity of injustice scale.

49. We can understand how distressing what happened must have been in the circumstances. But as we have explained above, we are not currently investigating complaints where there is a lower level of impact.

50. We are therefore satisfied an acknowledgement of the errors made and an apology for the impact is in line with our Principles which say a remedy should be fair, proportionate and reasonable. We can understand why Miss Y does not feel reassured the Trust will take the learning it has described. However, it has given these reassurances in writing which is what we would expect. We are also reassured through checking other complaints for the Trust that what Miss Y complained about has not been raised with us before.

51. We have decided not to take further action on this complaint. We recognise how important this complaint is to Miss Y, and we do not underestimate how distressing her experience has been. We would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and gives her some reassurances that the Trust followed relevant guidelines.

1. We thank Miss Y for giving us information on her concerns about Royal Devon University Healthcare NHS Foundation Trust the (Trust). We were sorry to hear about the circumstances that led her to bring a complaint to us. Particularly the distress and anxiety and overall impact this had on her son and their family since their experience.

2. After considering all of the information we have been given, we saw that the Trust followed the relevant guidance when it declined the first ENT referral, but the referral itself was not detailed enough, and had it been the referral would not have been declined. It appears this caused a month and a half delay in her son being put onto the list for surgery. It appears the family was not clearly told the first referral had been declined, which caused confusion and distress. We could not confirm what happened with the second referral because the Trust had no record of receiving and declining it.

3. We could not say the delay caused the wider impacts Miss Y described, such as the repeated antibiotics, hearing issues, speech delay or possible long-term ear problems. It appears the impact was mainly distress, frustration, uncertainty and inconvenience.

4. We saw that the Trust apologised and said it had taken learning around referral detail, communication and pathway oversight. Overall, we decided the impact was at a lower level of injustice, so we will not investigate further or take further action than has already been taken.

5. We recognise this was a worrying and upsetting experience for Miss Y and her family, particularly given her concerns about her son’s pain, hearing, speech and development. We hope that the information we have given below gives them some reassurances that the Trust has taken what happened seriously and taken action to learn and improve its services for the future.