George Eliot Hospital NHS Trust

4. Miss A complains about the care her son, O, received at George Eliot Hospital NHS Trust between 3 January and 11 March 2025 when he attended for blood tests following unexplained nosebleeds, bruising and fatigue.

5. Miss A says the Trust failed:

• to act promptly on O’s blood test results once they appeared showing low neutrophil (a type of white blood cell) counts, informing her more than two months later (on the 7 March 2025) in a routine follow-up appointment • to arrange an urgent assessment after a GP referral on 10 March 2025, instead telling the family to attend A&E without clear guidance • to provide a clear follow-up plan or communicate blood results after O’s A&E blood test on 11 March 2025, leaving the GP to chase after discharge • to make reasonable adjustments for O’s mental health conditions during the repeat blood test on 11 March 2025, resulting in Trust staff physically restraining him without explanation.

6. Miss A says the Trust’s failure to make reasonable adjustments for O’s mental health conditions during the A&E blood test on 11 March caused O to develop a lasting fear of medical procedures and hospitals, triggered nightmares and distress, and behavioural regression.

7. Miss A says the Trust’s delays in providing blood test results and slow responses to urgent GP referrals, caused a delay in the clinical decision to reduce O’s risperidone medication. She says this caused O to suffer symptoms longer than necessary and delayed his behavioural improvement.

8. Miss A says both of the above impacts combined to worsen O’s behaviour. Leading to increased violence and reduced school attendance. She says since the summer holidays in 2025, O has been unable to attend school causing more long-term impacts to O’s life.

9. Miss A says delays by the Trust caused herself and other members of O’s family to endure days of extreme anxiety, sleepless nights and uncertainty about O’s health, including fear he may have cancer.

10. Miss A seeks an apology, service improvements and a financial remedy.

11. O was 12-years-old at the time of treatment. He has autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and mild learning disability.

12. O has severe behavioural issues caused by his mental health conditions and has been taking risperidone (antipsychotic medication) since roughly 2020 to help manage this.

13. In early January 2025, Miss A raised concerns to O’s primary psychiatric care over symptoms of unexplained nosebleeds, bruising and fatigue. They took O’s bloods and sent the sample to the Trust for a full blood count review.

18. 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.

Failure to act promptly on test results

19. On 3 January 2023 O’s primary care sent O’s blood sample to the Trust for a full blood count review. The Trust performed the blood tests on 17 January. The results showed low neutrophil levels. The Trust decided the results were not abnormal enough to require a phone call to the primary care. The Trust electronically returned the blood results to the requesting clinician at O’s primary care centre and sent a paper version in the post.

20. Miss A says they only found out the results of the blood test during a routine appointment with the Trust on 7 March 2025.

21. Our paediatric adviser explains there is no official guidelines on specific timelines for communication of results.

22. GMC guidance makes it clear that it is the ordering doctors’ responsibility to inform the patient of results in a ‘timely fashion’.

23. The Trust did not order O’s blood tests. The Trust received the request and returned the blood test results to the ordering clinician. We consider it was not the Trust’s responsibility to inform Miss A of the blood test results and it acted in line with guidance in returning the results to the clinician who ordered the tests.

24. The Trust acted in line with the relevant guidance. We have seen no indications of maladministration or service failure.

Failure to arrange an urgent assessment after a GP referral

25. Miss A was concerned about the blood test results and contacted her GP. The GP referred O to the Trust’s paediatric department on 10 March. The Trust advised it had no urgent slots available. The next day, the Trust advised O to attend A&E for blood tests that day.

26. There are no national guidelines for management of urgent referrals. There was communication between the GP and Trust, and it agreed to see Daryl the next day.

27. Our paediatric adviser explains there is nothing to suggest O needed a medical assessment on the day and the Trust’s decision for O to attend A&E department the next day is a reasonable compromise.

28. Our paediatric adviser explains the Trust would have limited knowledge of O’s specific issues and there is nothing to suggest the Trust managed this referral in an inappropriate manner.

29. We consider the Trust acted appropriately when arranging O’s assessment following GP referral on 10 March and consider it offered an appointment at an appropriate time, after communicating with the GP.

30. We also recognise the Trust has apologised in its response to Miss A for failing to advise immediate Children’s Assessment Unit (CAU) attendance on 10 March. Within the response, the Trust outlined steps to develop a referral-documentation form to help improve future service. Both an apology and service improvements are part of Miss A’s desired outcomes.

31. We have seen no indications of maladministration or service failure in this issue.

Failure to provide a clear follow-up plan or communicate blood results

32. After the Trust had taken O’s blood sample on 10 March, it allowed O to leave before his blood test results had returned. The Trust made a note for O’s GP to ‘chase’ after discharge (leaving responsibility with the GP to obtain the results).

33. Miss A was concerned about the potential outcome of the blood tests and repeatedly called the Trust for the results. Miss A received the results from the Trust the next day. O’s neutrophil levels had improved.

34. Our paediatric adviser explains there was evidently some confusion with whether the GP expected the Trust to be purely an emergency phlebotomy service or if it should have provided an assessment and, if necessary, treatment for O.

35. Our Adviser says the records show even if the Trust should have provided an assessment, the results of O’s repeat blood tests meant he would have been discharged back to his referring doctor, with no further in treatment indicated.

36. Our Adviser says it is difficult to predict how long it takes for blood test results to return from pathology. Being in hospital was stressful for O and sending him home before the results had returned seems reasonable.

37. We consider the Trust acted in line with guidance when communicating blood test results. We have seen no indications of maladministration or service failure in this issue.

38. We can see the Trust’s local resolution response says it regrets not providing O’s results to the family on the day. It apologises for leaving result-ownership with the GP and outlined steps to establish clear responsibility for result follow-up and to create audit trails. This shows the Trust have taken action to acknowledge and improve its service as a result of Miss A’s complaint.

Failure to make reasonable adjustments during repeat blood test

39. Miss A says when they arrived at A&E on 11 March, they had to wait in a busy area for a long time.

40. When Trust staff did attend to O, Miss A says they restrained him for the sample without warning. Miss A says the Trust did not make reasonable adjustments for O’s mental health conditions and the treatment left him traumatised.

41. From the evidence provided, we can see:

• a Trust nurse triaged O within seven minutes of his arrival at A&E • the Triage assessment raised no concerns • the Trust performed O’s treatment in a room away from the waiting area • the Trust used a Play Specialist to support while taking O’s bloods • O left the department approximately one hour after arriving.

42. Our nurse adviser explains the care provided by the Trust demonstrates appropriate nursing care.

43. The Royal College of Emergency Medicine recommends supporting patients with learning disabilities by finding a quieter area to preform treatment and considering ways to reduce the sensory overwhelm.

44. We consider the Trust acted in line with this recommendation when providing reasonable adjustments for O during the repeat blood tests. The Trust took O to a quieter area for treatment, involved a play specialist to support O and completed treatment in a timely manner. We consider this shows a consideration to reduce sensory overwhelm and provide reasonable adjustment for O.

45. We have seen no indications of maladministration or service failure in this issue.

46. We thank Miss O for bringing this complaint to us. We appreciate the time and effort this took and hope our investigation can provide some closure to the difficult events Miss A and O experienced.

1. We have carefully considered Miss A’s complaint about George Eliot Hospital NHS Trust (the Trust).

2. We recognise the difficult and stressful circumstances involved in this complaint, we have seen no indication that anything went wrong.

3. We explain this decision in more detail below.