South Tees Hospitals NHS Foundation Trust

4. Miss A complains about the standard of care she received from the Trust when she went in for a myomectomy procedure on 14 November 2023. Specifically, she complains that: • the Trust inappropriately administered Miss A with a spinal anaesthetic prior to her having a myomectomy • the Trust did not inform her of the risk of spinal neuropraxia from having a spinal anaesthetic prior to her having surgery • the Trust did not provide her with adequate pain relief after her surgery • the Trust did not provide her with personal care needs when she was in the post-operative surgical day unit • the Trust wrongly told her she did not need tinzaparin in her discharge plan • the Trust unsafely discharged her from the Trust.

5. Miss A says that she has been left with nerve damage in her bowel, bladder and left leg because of the spinal anaesthetic. Miss A says this has negatively impacted on her quality of life and this has caused her a lot of distress.

6. Miss A says she was caused distress and concern about being unsafely discharged from the Trust. She says she had to arrange for her own mobility equipment to be delivered to her home.

7. Miss A says she was caused added concern and distress due to her being wrongly told she did not need tinzaparin.

8. Miss A says she was left in pain after not receiving adequate pain relief.

9. Miss A says she was caused added distress because of the Trust not attending to her personal care needs.

10. Miss A seeks an acknowledgement of failings, an apology, and a financial remedy in line with the Ombudsman’s scale of injustice guidance.

11. Miss A had a myomectomy on 14 November 2023 to remove fibroids, usually via the abdomen, from her Womb without removing it. She says she was told she would be discharged no later than the next day.

12. Before Miss A’s surgery, she was given a spinal block for the pain. Miss A says she was reluctant to have this, but the Trust informed her this was the best option as other forms of pain relief would affect her whole body.

13. Miss A said the surgeon did not go through any alternatives with her, and she was given the spinal block and general anaesthetic.

Spinal anaesthetic

17. Miss A says the Trust inappropriately gave her a spinal anaesthetic prior to her having a myomectomy on 14 November 2023. Miss A also says the Trust did not warn her that the spinal anaesthetic may lead to spinal neuropraxia, and she says she felt pressured into having this anaesthetic. Miss A says she has been left with nerve damage in her left leg, bowel and bladder because of the spinal anaesthetic.

18. Miss A has provided us with a copy of the consent form for her myomectomy procedure which outlines the risks of the surgery including infection, bleeding and pain. Miss A says there is no mention of nerve damage on the consent form, and she says she was never informed of the possibility of suffering femoral nerve damage or spinal neuropraxia prior to her surgery.

19. Femoral nerve damage occurs when the nerve running down the front of the thigh is damaged, compressed, or stretched. It primarily causes weakness in straightening the knee, deep groin pain, and numbness or tingling in the front of the thigh and inner lower leg.

20. A spinal anaesthetic is a local anaesthetic injected into the lower back (between the bones of the spine). It provides anaesthesia from the waist down so the patient does not feel any discomfort during the operation.

21. Spinal neuropraxia is a temporary nerve injury often caused by brief mechanical contact (like a needle brush) during a spinal anaesthetic. While it can cause temporary numbness, tingling, or muscle weakness, the nerve pathways remain structurally intact, meaning a full recovery is expected within days or weeks.

22. In its response, the Trust said the anaesthetist felt they had taken the time to discuss the spinal anaesthetic with Miss A at the time, and they apologise if this was not her experience. The Trust stated that on the day of her surgery, the anaesthetist took Miss A’s anaesthetic history, asked about her previous anaesthetics, her medical history, fasting status and they performed an assessment of Miss A’s airway.

23. The Trust added that for an open myomectomy (where an incision is made into the lower abdomen to access the uterus), the anaesthetist informed Miss A she would need to have a general anaesthetic, and they discussed what would happen in the anaesthetic room. This included the possible post-operative risks of pain, nausea, sore throat, dental/oral damage, anaphylaxis (allergic reaction), and confusion.

24. The Trust said due to this type of operation being more painful, the anaesthetist offered Miss A a spinal anaesthetic and started to discuss the benefits of pain relief and the risks, including the possibility of needing a catheter.

25. The Trust said the anaesthetic chart that documents the discussion regarding possible complications had prompts for the known complications of all the anaesthetic techniques and the ones discussed with patients are circled. The anaesthetist circled those they felt were relevant to your Miss A’s case, including temporary and permanent nerve damage.

26. The Trust explained the anaesthetist outlined they normally ask patients if they have any questions at that time, and they hope they offered Miss A this opportunity. The Trust said the documentation supports the anaesthetists thinking that there were no problems with performing the anaesthetic.

27. To determine if it was appropriate for the Trust to give Miss A spinal anaesthesia prior to her surgery, we have referred to the Royal College of Anaesthetists guidance on spinal anaesthetic. We have also referred to the Association of Anaesthetists guidance on consent for anaesthesia. Miss A’s clinical records show she had both a spinal anaesthetic and general anaesthetic prior to her having surgery.

28. The Royal College of Anaesthetists guidance outlines this provides anaesthesia from the waist down so the patient does not feel any discomfort during the surgery. It states that the anaesthetic can be used on its own, or with a general anaesthetic for gynaecology surgery such as a hysteroscopy (a test to look inside a woman's womb) and some types of hysterectomy (a surgical procedure to remove the womb (uterus)). Miss A had gynaecology surgery and so the guidance indicates this would have been appropriate for Miss A’s surgery.

29. We also obtained clinical advice on this from our anaesthetist adviser on the appropriateness of providing Miss A with a spinal anaesthetic. Our anaesthetist adviser stated spinal anaesthetic to put in morphine or similar medication close to the spinal cord prior to a general anaesthetic for surgeries such as Miss A’s is a recognised technique. Our adviser stated this helps in ensuring good pain relief for after the operation without the side effects of intravenous morphine or similar medication, as this (myomectomy) can be a painful operation.

30. Based on the Royal College of Anaesthetists guidance we have considered and the clinical advice we have received, we have found it was appropriate of the Trust to give Miss A a spinal anaesthetic prior to her surgery.

31. With regards to Miss A being appropriately consented to the potential risks and complications of the spinal anaesthetic, we have reviewed the anaesthetic records dated 14 November 2023 (the date of Miss A’s surgery). There is a section in the records titled ‘anaesthetic consent/discussion: the following have been discussed with the patient…’ we can see that the anaesthetist circled both temporary nerve injury and permanent nerve injury in this section, to indicate that that the anaesthetist had discussed both of these potential risks with Miss A prior to her surgery.

32. The Trust also stated it provided Miss A with a leaflet on anaesthesia on the day of her surgery. We of course understand that Miss A says she was never informed of the risk of nerve damage. It is important to consider our role to assess these issues by considering all available evidence and determining what is more likely than not to have occurred. In doing so, we can place weight on documented evidence, and relevant specialist advice when evaluating the likely impact of the Trust’s actions. Whilst we do not dispute what Miss A says, we must be objective and evidence based in our findings.

33. The Royal College of anaesthetic guidance on the risks and side effects of spinal anaesthetics states a single nerve, or a group of nerves may be damaged. Therefore, the area affected may be small or large. In its mildest form you can get a small numb area or an area of ‘pins and needles’ on your skin. There may be areas of your body that feel strange and painful. Weakness may occur in one or more muscles, and the most severe (and very rare) cases give permanent paralysis of one or both legs (paraplegia) and/or loss of control of the bowel or bladder. The guidance outlines most people make a full recovery over a period of time between a few days and a few weeks, and permanent damage is very rare.

34. The AAGBI guidance on consent for anaesthesia (2017) outlines that a signed consent form is not necessary for anaesthetic procedures that are done to facilitate another treatment. Since it is the process of consent itself that is important, a signed form is evidence that a consent process has been undertaken but does nothing to validate or invalidate the consent.

35. Our anaesthetist adviser stated that the Trust’s anaesthetist documented that they discussed the procedure with Miss A, along with the associated risks including temporary and permanent nerve damage. We asked our anaesthetic adviser did they consider the anaesthetic records showed that Miss A had provided informed consent to have the spinal anaesthetic.

36. Our adviser stated there is no requirement for written consent (from the patient) for anaesthesia and anaesthetic procedures, and so they would not expect to see Miss A’s written consent for the anaesthetic. They stated the consent form would be completed by the anaesthetist, to indicate that the discussions (regarding the risks of the anaesthetic) have taken place.

37. Whilst the risk of nerve damage was not indicated on the surgical consent form, it was indicated on the anaesthetic consent form in relation to the spinal anaesthetic, which is where we would expect to see it highlighted.

38. However, we can see from the Trust’s response that its discussion with Miss A around the risks of the anaesthetic was interrupted by the surgical team. This would not have been an ideal situation for Miss A, having an important discussion interrupted at what was almost certainly a very difficult and stressful time for her. It is possible this adversely impacted how the anaesthetist was communicating the risks of the anaesthetic to Miss A, and that it potentially impacted on her understanding of this at the time. We also note that whilst the anaesthetist indicated the risks they say they discussed with Miss A on the consent form, there is no separate documentation to detail the discussion that the anaesthetist had with Miss A.

39. The AAGBI guidance on consent for anaesthesia (2017) says it is essential for anaesthetists to document clearly both a patient’s agreement to the intervention and the discussions that led up to that agreement including the patient’s questions and the responses given. This can be done on the standard consent form, the anaesthetic record or separately in the patient’s notes. A pro-forma may be useful, but as a guide to the conversation, not as a checklist to be ticked off without recording further detail.

40. Whilst we have not identified a failing here, we would ask the Trust to reflect on this and to put in place a procedure and protocol to ensure that discussions from both the surgical team and the anaesthetist with the patient are structured and documented prior to surgery. This is to prevent a similar situation occurring whereby an important discussion with a patient is interrupted by a differing clinical team and it is to ensure discussions are documented clearly and thoroughly in the patient’s records.

41. Ultimately, we cannot say with certainty what Miss A was and was not informed of prior to her surgery, as we were not privy to the conversations she had with the anaesthetist. We must base our findings on the evidence available to us, which in this case is Miss A’s account, the Trust’s response to her complaint, and Miss A’s clinical records. There is clearly a conflicting account of events with regards to what took place. The clinical records do corroborate what the Trust has said in its response.

42. Whilst we cannot say this is what happened, we also cannot say Miss A was not appropriately consented for the spinal anaesthetic, based on the evidence we have seen. After careful and robust consideration, we have not identified a failing with how the Trust consented Miss A for her anaesthetic. We understand this will be upsetting for Miss A, and we do understand she has been through an extremely difficult and traumatic time since the date of her surgery.

Pain relief after Miss A’s surgery

43. Miss A says the Trust did not provide her with appropriate pain relief (analgesia) after her surgery, and she was left in pain for periods of time.

44. In its response to her complaint, the Trust addressed pain relief in point five of its response. This was in relation to the pain relief Miss A received when she was on ward eight on 17 November 2023. It stated it prescribed Miss A with paracetamol to take every four hours, ibuprofen to take every eight hours, and morphine solution for breakthrough pain.

45. The Trust said the records show these were administered within accordance of the pain assessments that were carried out. The Trust apologised to Miss A that the analgesia she was given did not relieve her pain, and it would expect that further requirements for pain relief to be escalated to the pain team so an increase in frequency of pain medication could be prescribed. The Trust said this will be discussed at the patient safety huddles.

46. The Trust also addressed pain relief at point nine of its response, this relates to when Miss A was on the Post-Operative Surgical Day Unit (POSDU) from 15 to 17 November 2023. It stated Miss A’s pain levels were assessed hourly for the first 24 hours, which is a requirement when someone has had a spinal anaesthetic.

47. The Trust said Miss A’s pain levels were then assessed every four hours until 17 November 2023. It outlined that on 15 November 2023 at 9:02am Miss A had a pain score of 7/10 (10 being very strong pain), but she did not receive analgesia until 10:20am. Miss A was reassessed for pain at 10:50am and remained 7/10 and she was given analgesia. The Trust went on to list various points when Miss A was assessed for pain and when she was given pain relief on 15 November 2023.

48. The Trust outlined there was no evidence of the Trust completing any pain assessments after 9:34am. The Trust stated it should have outlined that Miss A’s pain score was over four when she transferred to ward eight later that day, as this would have indicated her pain needed further management prior to travelling. The Trust stated it is clear that on three occasions across Miss A’s stay, she waited far longer than was acceptable for pain medication, and longer than the maximum time of 45 minutes to evaluate the effectiveness of the analgesia that was administered. The Trust apologised for the delayed administration of the pain medication, and it apologised that pain reassessments did not take place as they would be expected to be.

49. When looking at the pain relief the Trust provided to Miss A, we also reviewed the NMC guidance on Standards of proficiency for registered nurses. Annexe 3 of the guidance states nurses should observe and assess comfort and pain levels, and they should take appropriate action to reduce or minimise pain or discomfort.

50. We also reviewed Miss A’s clinical records from the time she was receiving pain medication from the Trust, and we received clinical advice on this from our nursing adviser.

51. Our nursing adviser stated Miss A’s pain was scored as a four when she moved back to the ward. We can see from Miss A’s clinical records that Miss A was given ibuprofen and paracetamol were given to her regularly. She was provided with Oramorph on an as needed basis. The Trust documented this was given to her four times on the afternoon and evening of 14 November 2023, seven times on 15 November, four times on 16 November, and three times on 17 November. The Trust also administered tramadol (a stronger painkiller) to Miss A twice on 16 November. Our clinical adviser outlined the Trust gave Miss A appropriate pain relief.

52. However, we can see the Trust has acknowledged that it failed to appropriately assess Miss A for pain relief as much as it should have done, and it failed to provide Miss A with pain relief as quickly as it should have done on three occasions, this meant Miss A was waiting longer than she should have for pain relief. We have found this is a failing with how the Trust managed Miss A’s pain relief. We will discuss the impact of this later in the report. We can also see the Trust has outlined it has taken actions to mitigate against the chances of this happening again, and we will also discuss this later in the report.

Personal care needs

53. Miss A says the Trust did not provide her with personal care needs when she was in the POSDU.

54. In its response, the Trust stated that there was no reference in Miss A’s records that related to nursing staff meeting her personal care needs. It stated that it identified a staff member recalled wheeling Miss A to the shower room with her toiletries on the morning of 16 November 2023. However, the Trust stated that given the lack of nursing notations, recollections by staff and Miss A’s own account, it can be assumed Miss A was not given the fundamental basic care expected by a patient whilst in the care of the Trust. The Trust apologised that this did not happen. The Trust said it will discuss Miss A’s experience with the POSDU team to highlight the standard expected in relation to patient’s personal care needs and appropriate documentation of this. The Trust said it will also review care plans regularly to ensure this requirement is met and maintained.

55. It is clear from the Trust’s response that the Trust failed to meet Miss A’s personal care needs when she was an inpatient at the Trust. However, to robustly assess this, we have reviewed Miss A’s clinical records, and we have received clinical advice on this from our nurse adviser. We have also reviewed the Standards of proficiency for registered nurses’ guidance.

56. Section 4.1 of the guidance states that nurses should observe, assess, and optimise skin and hygiene status and determine the need for support and intervention. Section 4.3 of the guidance states that nurses should assess needs for, and provide appropriate assistance with washing, bathing, shaving and dressing. Section 1.2.9 of the NICE guidance on the patient experience in an adult NHS setting, outlines that clinicians should ensure that the patient's personal needs (for example, relating to continence, personal hygiene and comfort) are regularly reviewed and addressed. The guidance states that clinicians should regularly ask patients who are unable to manage their personal needs what help they need, and they should address their needs at the time of asking and ensure maximum privacy.

57. We have reviewed Miss A’s clinical records, and we could not find any evidence within the records to show the Trust was meeting the guidance we have outlined by attending to Miss A’s personal needs. Miss A’s hygiene assessment record and her comfort round charts are blank, which shows the Trust did not complete the records and it strongly indicated the Trust was not meeting Miss A’s personal care needs when she was an inpatient at the Trust. The only reference to Miss A’s personal care needs was on 18 November 2023 (the day she was discharged from the Trust) where the Trust stated Miss A was independent with her hygiene needs. Our nurse adviser stated there is no evidence that the Trust supported Miss A in meeting her hygiene needs.

58. After careful and robust consideration of Miss A’s clinical records and the guidance we have looked at, we have identified a failing with how the Trust cared for Miss A when she was an inpatient, as there is no evidence it took steps to try and meet her personal care needs. We have found the Trust failed in its duty to meet Miss A’s personal care needs when she was an inpatient. We will discuss the impact of this later in our report.

Prescription of tinzaparin

59. Miss A says the Trust wrongly told her she did not need tinzaparin in her discharge Plan, but then it told her she did need it after she had been discharged.

60. In its response, the Trust stated that during Miss A’s initial conversation with the Trust regarding the tinzaparin, the Trust would have referred to her discharge letter in relation to tinzaparin administration. The Trust stated that following a review of this, the gynaecology medical team had not documented a plan for tinzaparin for when Miss A was discharged from the Trust. The Trust apologised to Miss A for not providing her with the correct information and it said this has been shared with the Clinical Director for Gynaecology for discussion at the Directorate meeting.

61. Tinzaparin is a medication that is prescribed to prevent blood clots and deep vein thrombosis from forming during and after surgery, particularly in patients with limited mobility or acute medical illnesses. Deep vein thrombosis specifically is a blood clot that develops in a deep vein, usually in the leg or thigh, though it can also occur in the arms or pelvis.

62. Based on the response the Trust has provided to Miss A, it is clear the Trust has acknowledged that it should have prescribed Miss A with tinzaparin when she was discharged from the Trust, and it did not do this.

63. To determine if there has been a clinical failing here, we have reviewed the NICE guidance on discharge planning, we have reviewed Miss A’s clinical records, and we have received clinical advice from our gynaecology adviser. Sections 1.5.3, 1.5.4 and 1.5.5 of the guidance concern information sharing within a hospital setting. They state the following:

1.5.3: Health and social care organisations should agree clear discharge planning protocols.

1.5.4: Ensure that all health and social care practitioners receive regular briefings on the discharge planning protocols.

1.5.5: During discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital and communitybased multidisciplinary teams.

64. Based on the guidance we have outlined, it is clear the Trust should have a clear process in place to ensure that information is shared with the clinicians who are directly involved with discharging the patient to ensure all the appropriate medications are prescribed to the patient, and the patient is given all the necessary information prior to the Trust discharging the patient. This did not happen here as Miss A was not prescribed tinzaparin as she should have been when she was discharged, and she was left wondering whether she should have been prescribed it in the days after her being discharged from the Trust.

65. We have reviewed Miss A’s clinical records, and her operation record and inpatient prescription states the Trust intended for Miss A to have the medication for two weeks after her surgery. Miss A’s clinical records show the medication was only administered to her for four days after her surgery (i.e. the time she was an inpatient at the Trust) and she was not prescribed tinzaparin on her discharge letter, so it is clear the Trust did not administer this in line with the prescribers’ instructions.

66. Our gynaecology adviser stated Miss A should have been prescribed tinzaparin when she was discharged from the Trust to help prevent her from getting deep vein thrombosis. Our gynaecology adviser stated the Trust put Miss A at increased risk of deep vein thrombosis by only administering tinzaparin to her for four days instead of 14, as was outlined on her prescription record.

67. After carefully reviewing all the evidence here, we have identified a failing with the Trust’s failure to prescribe Miss A with tinzaparin on her discharge letter when she was discharged from the Trust as an inpatient on 18 November 2023. We will discuss the impact of this in the impact section of our report. We understand this must have been a very worrying time for Miss A.

Miss A’s discharge from the Trust on 18 November 2023

68. Miss A says she felt her discharge was unsafe as she was struggling with her mobility after she was discharged home, and she had to arrange for her own mobility equipment to help her move around her house.

69. In its response to Miss A, the Trust stated the discharge arrangements were coordinated by the physiotherapy team, which include a follow up from the Urgent Community Response Team (UCRT), who were supposed to visit Miss A within two hours of her being discharged home. NHS England outline that UCRT’s provide urgent care to people in their homes which helps to avoid hospital admissions and enable people to live independently for longer.

Through these teams, older people and adults with complex health needs who urgently need care, can get fast access to a range of health and social care professionals within 2 hours. This includes access to physiotherapy and occupational therapy, medication prescribing and reviews, and help with staying well-fed and hydrated.

70. The Trust stated there is no record of the nursing team having contacted the UCRT to ask them to visit Miss A when she was being discharged from the Trust, and therefore, the UCRT were not informed Miss A was discharged from the Trust. The Trust apologised that this was not done, and that Miss A was left struggling at home. The Trust stated it had discussed this with the nursing team to ensure that on the contact telephone calls are made when the patient is discharged, and a second signatory has been added to the discharge checklist, to confirm that all actions have taken place. The Trust added that the physiotherapy team is reviewing the discharge process, with regards to a cut-off time being agreed to ensure a safe discharge, with the correct follow up.

71. It is clear the Trust has acknowledged a failing in communication with the UCRT as part of the discharge process. However, to robustly investigate this part of Miss A’s complaint, we have reviewed the NICE guidance on discharging patients from hospital, we have received clinical advice on this from our nurse adviser, and we have reviewed Miss A’s clinical records.

72. Section 1.5.5 of the NICE guidance states that during discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital and communitybased multidisciplinary teams.

73. Miss A’s clinical records show that on 18 November 2023, the physiotherapist assessed her in preparation for Miss A being discharged from the Trust to go home. The physiotherapist advised Miss A it was not safe to go home as she had not done a stair assessment (to ensure Miss A was able to walk up and down stairs safely). The physiotherapist referred Miss A to the UCRT for a two-hour response, and they documented that nurses were advised to contact the UCRT when Miss A had been discharged from the Trust.

74. The physiotherapy assessment concluded Miss A was independently mobile with a Zimmer frame. Miss A advised the physiotherapist that she would be living downstairs, she did not want to wait for a stair assessment, and it is documented she had capacity to make that decision. Our nursing adviser outlined that Miss A was therefore safe to go home with ongoing physiotherapy and the UCRT.

75. It is documented within the nursing documentation that Miss A was discharged on the afternoon of 18 November 2023, and that ‘community therapies were to go and see her that evening’.

76. Based on all the evidence and guidance we have considered, we have found that whilst Miss A was suffering with mobility issues on the day she was discharged from the Trust, the decision to discharge her was appropriate, considering the clinical advice we have received, and Miss A advising the physiotherapist she would be living downstairs. However, we have identified a failing with the Trust’s failure to inform the UCRT that Miss A was being discharged from the Trust to go home. We understand this must have been a very distressing time for Miss A. We will discuss the impact of this later in the report.

77. We understand Miss A has been through an extremely difficult time since her surgery in November 2023, and the issues we have identified have added to her distress.

Our findings in relation to impact

78. We have identified four failings with the level of care Miss A received from the Trust from 14 November to 18 November 2023. We will address the impact we have identified for each of these.

Lack of pain relief

79. We identified the Trust failed to adequately monitor Miss A’s pain relief and provide Miss A with pain relief in a timely manner. We have found this would have led to Miss A being in pain for longer than she should have been during time she was an inpatient at the Trust. This would likely have added to Miss A’s distress at what was already a very difficult time for her post-surgery as she was suffering from numbness in her left leg and she was unable to mobilise properly. This would likely have added to Miss A’s feeling of vulnerability whilst she was an inpatient at the Trust.

Personal care needs

80. We have found that Miss A’s personal care needs were not assessed or delivered when she was at the Trust. Our nursing adviser stated this is a fundamental aspect of nursing care. We have found the lack of nursing support with Miss A’s hygiene needs would have impacted on her cleanliness, comfort and dignity at what was a very worrying and distressing time for Miss A. Miss A was particularly reliant on nursing care for her needs to be met post-surgery, and the Trust’s failure to do this would have added to her distress.

Tinzaparin

81. We have found that the Trust failed to prescribe Miss A with tinzaparin when she was discharged. Miss A was supposed to take this medication for two weeks from her surgery, but she was only given this for four days when she was an inpatient due to the Trust’s failure to prescribe it on her discharge letter.

82. Whilst we have seen no evidence that Miss A suffered a blood clot or deep vein thrombosis as a result of not being prescribed this post-discharge, we have found Miss A would have been caused added worry, concern and uncertainty due to the miscommunication from the Trust.

83. Miss A was unclear whether she should have been prescribed tinzaparin when she was discharged. Miss A then learned she should have been prescribed it on discharge from the Trust, but she was not. This meant she was not taking this medication after she was discharged from the Trust.

Miss A’s discharge from the Trust

84. Whilst we did not find a failing with the Trust’s decision to discharge Miss A on 18 November 2023, we have found the Trust’s failure to contact the UCRT when Miss A was discharged caused her added concern.

85. Miss A says she had to order her own mobility equipment, and her children had to provide care for her for the first few days after she was discharged. Miss A states she could not mobilise around her house. This would no doubt have caused Miss A added alarm, worry and distress at what was already a very difficult time for her.

1. We were very sorry to learn of the issues Miss A has brought to us. We understand she has been through an extremely difficult, worrying and distressing time since she had her myomectomy on 14 November 2023 to the present day. We sincerely hope our investigation can provide Miss A with some closure to her complaint.

2. After robustly investigating the issues Miss A has brought to us, we have identified four failings with the standard of care Miss A received from the point of her surgery on 14 November 2023 up until the point she was discharged as an inpatient from the Trust on 18 November 2023. We will be partly upholding the complaint overall.

3. We will be making recommendations as a result of the issues we have investigated. We will explain this in our report.

Our recommendations

86. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

87. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale (our scale).

88. Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstances.

89. We understand in its 9 July 2024 response to Miss A, the Trust apologised to her for the failings we have identified. We also acknowledge the Trust said it would be carrying out some actions to improve its services in the areas where it identified failings.

90. After carefully reviewing the response, we do not consider the apologies fully acknowledge the impact the failings had on Miss A. With regards the action plan, the Trust has not provided any evidence of improvements to services in these areas.

91. Therefore, based on the failings and the impact to Miss A that we have identified, we recommend that following our final report the Trust should write to Miss A within one month of the date of our final report to apologise to Miss A for the failings we have identified, and the impact these failings had on Miss A. We also ask a copy of the apology letter is sent to our office.

92. We recommend the Trust explains what actions it will take, or has taken, to address these failings within three months of the date of our final report. This should be in the form of an action plan. Specifically, the action plan should address:

• how the Trust will ensure its consent process for patients having surgery is structured, and how the Trust will document the consent discussions the clinicians and anaesthetists have with a patient prior to their surgery • how the Trust will make service improvements with regards to assessing pain levels and then administering pain relief for patients on the POSDU • how the Trust will ensure robust checks are done to ensure all of the patient’s medication that was prescribed post-surgery is included on the patient’s discharge letter • how the Trust will ensure that patient’s personal needs are met when they are on the ward post-surgery, particularly patients who have mobility needs and are unable to mobilise post-surgery • how the Trust will ensure that robust checks are done to ensure discharge planning arrangements are met at the point of discharge, and that all of the discharge planning arrangements are documented on the patient’s discharge letter to ensure their discharge back into the community and their transfer of care back to their GP or the community care providers is seamless • if the Trust considers it has already completed the above actions, the Trust should write to Miss A and our office with the evidence of the service improvements being implemented.

93. When making recommendations, we also consider if a financial remedy is appropriate, in line with the NHS Complaints Standards. In line with our guidance on financial remedy, we recommend that the Trust should provide Miss A with a financial remedy of £550. This figure sits at the top of level two on our scale of injustice.

94. Our guidance says a level two injustice will typically arise when what has gone wrong has had a relatively low impact on the person affected. This 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 once or was of short duration. In these cases we consider that an apology is not suitable by itself.

95. We of course understand that Miss A holds the Trust responsible for the lack of mobility in her left leg, and the lack of sensation she had suffered in her bladder and bowel area since her surgery in November 2023.

96. As we explained earlier in our report, we did not identify a failing with the spinal anaesthetic being administered, or how Miss A was consented for this (we understand Miss A says the Trust never informed her of the possibility of nerve damage prior to her surgery). This means we would not be able to link any of the significant impact to her quality of life with regards her mobility that Miss A claims.

97. It is important our financial remedy is directly reflective of the impact that we have identified that flows directly from the failings we have identified. As this is the case, the financial remedy we have recommended is not intended to be reflective of the impact Miss A claims to have suffered continuously from the time of her surgery to the present date, but it is reflective of the impact we have outlined in the section above.

98. Therefore, based on the impact we have identified, we consider the impact of the four failings when considered together makes the impact to Miss A more signification due to the cumulative effect of the added distress brought about by each of these failings. Based on this rationale, we consider Miss A’s impact sits at the top of level 2, and so we consider a financial remedy of £550 is appropriate.

99. We will ask the Trust to send us evidence it has completed all the recommendations we make in the final report. We will check the action plan includes the reason for the failing (where possible), what the Trust does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.

Conclusion

100. We have been extremely sorry to learn of Miss A’s complaint and understand Miss A has been through a very difficult time since November 2023. We sincerely hope the findings set out in this report can bring some closure on this for Miss A.