University Hospitals Coventry and Warwickshire NHS Trust

4. Miss Y went to the Trust on 5 August 2024 with pain in her kidney and bladder. She complains about the care and treatment provided by the Trust. She complains; • she was not granted a second opinion on her care aside from Dr X • the Trust wrongly identified she had a kidney stone measuring 1.8mm • PALS took too long to respond to her concerns.

5. Miss Y told us the Trust’s failure to provide a second opinion contributed to her diagnosis and prolonged pain. Miss Y said she was in pain for an additional week before her kidney stone was correctly diagnosed as measuring 4.8mm. Miss Y lost trust in the NHS and flew to Moldova for treatment.

6. Miss Y told us the delay in the Trusts complaint handling was very stressful and she could not sleep. Miss Y has lost trust in the NHS complaint process.

7. Miss Y would like the Trust to implement service improvements that improve how doctors listen to patients. She would also like financial compensation of between £120-£1,200.

Issue 1 - Miss Y was not granted a second opinion on her care aside from Dr X

12. 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.

13. Miss Y told us Dr X was responsible for her care during her inpatient stay. Dr X is a lead consultant specialising in general internal medicine. Miss Y said she was not happy with the care Dr X provided as she felt Dr X did not listen to her. Miss Y asked for a different consultant to take over her care on 8 August as she wanted a second opinion on her condition.

14. The Trust records show on 6 August, Miss Y asked for a urologist’s opinion on her care. The Trust records show on 8 August at 12pm Miss Y requested to speak to another senior clinician before she was discharged from the Trusts care. Dr X said this was not possible.

15. On 9 August a urology specialist (the Urologist) was asked to review Miss Y’s notes and check whether Miss Y was suitable for discharge. The Urologist reviewed Miss Y, agreed Miss Y was suitable for discharge and booked a routine outpatient appointment for her.

16. On 9 August security was called after Dr X and Miss Y had a heated conversation around the bed space. A Nurse (the Nurse) came over to calm down the situation. The Nurse noted in the records she would try and arrange a different consultant to take over Miss Y’s care as the relationship between Miss Y and Dr X had broken down.

17. Miss Y’s discharge summary was entered at 3pm on 9 August 2024. The lead consultant was listed as Dr X.

18. In the Trust’s complaint response it said the Urology department provided input on Miss Y’s care which acted as a second opinion. All blood tests, radiology investigations, and observations all indicated Miss Y was safe for discharge.

19. Our adviser referred us to GMC guidance. GMC guidance says a patient’s request for a second opinion should always be carefully considered and it should be accommodated if appropriate. The decision on how to respond to such a request remains a matter of clinical judgement. The organisation should consider the patient’s concerns, clinical need and service availability.

20. Miss Y had specialist input from the Urologist on 9 August and had a planned outpatient appointment. It was therefore appropriate for the Trust to consider it was not clinically necessary for Miss Y to have the opinion of a second consultant.

21. When the Nurse considered Miss Y may need a different consultant to take over her care, Miss Y had already been recorded for discharge. It was not appropriate for Miss Y to have a second opinion at this stage.

22. For this reason, we can find no indications of maladministration in the Trusts actions.

23. Miss Y may be reassured that if another consultant had reviewed her, we consider they would have likely come to the same conclusion as Dr X. This is because Miss Y’s scan had been incorrectly reported by the radiologists. We consider if another consultant had reviewed Miss Y’s condition, using the same incorrect report, they would not have changed the decision to discharge Miss Y.

Issue 2 - The Trust wrongly identified Miss Y had a kidney stone measuring 1.8mm

24. Miss Y told us she felt the Trust did not listen to her when she kept telling them she had kidney and bladder pain. Miss Y complains the Trust wrongly diagnosed the size of her kidney stone.

25. The Trust records state Miss Y was admitted on 5 August with kidney and bladder pain. Miss Y had a CT scan at 9am on 6 August. The CT scan report states Miss Y had a 1.8mm kidney stone. This size of kidney stone does not block urine flow and often carries no symptoms. The CT scan found no other abnormalities.

26. Miss Y returned to the Trust on 12 August. The Trust reviewed Miss Y’s CT scan from 6 August. The Trust acknowledged the stone size had been wrongly reported, and it measured 4.8mm. The Trust ordered a second CT scan of the kidney, uterus and bladder, which confirmed the size of her kidney stone was over 4mm.

27. The Trust explained the CT findings to Miss Y. The Trust records say it gave Miss Y two options. The Trust said Miss Y could stay overnight for pain relief monitoring or be discharged. Miss Y asked to be discharged. She was discharged with five days’ worth of diclofenac and paracetamol for pain relief.

28. We have seen an indication of a failing in the Trust’s measurement of Miss Y’s kidney stone.

Issue 3 – PALS took too long to respond to her concerns

29. Miss Y told us she first complained to the Trusts complaint department (PALS) on 8 August 2024. She told us she emailed, called and spoke to PALS in person to ask for updates. Miss Y became concerned the Trust had not responded to her complaint, and she contacted us on 29 July 2025.

30. From the Trusts complaint correspondence, we can see the Trust responded to Miss Y on 6 August 2025. We looked at the evidence from Miss Y and the Trust to understand why the Trust took a year to respond to Miss Y’s complaint.

31. Miss Y first raised concerns with her treatment whilst she was still an inpatient at the Trust on 8 August 2024. PALS responded and said it would deal with Miss Y’s concerns in five working days. Miss Y’s complaint was given reference number A.

32. On 9 August 2024 the Matron of Miss Y’s ward emailed PALS to say they had been with Miss Y and discussed all her concerns with her. Miss Y was discharged from the Trust later that day.

33. On 10 August 2024, Miss Y emailed PALS stating she was still dissatisfied with her care. Miss Y’s concerns were vague, but her core issues were: • she was not given a right to a second opinion • and she had been discharged without a diagnosis and relief of her symptoms.

34. We can see from the Trust’s complaint file PALS received Miss Y’s email, but Miss Y received no acknowledgment.

35. On 2 October 2024 Miss Y emailed PALS to say she hadn’t received a complaint response. Miss Y attached her emails from 8 August and 10 August. On 16 October 2024, PALS responded to say Miss Y’s complaint had been given reference number B. It said it would aim to manage Miss Y’s concerns within 5 working days.

36. PALS then contacted relevant medical personnel at the Trust to gain insight on the complaint. PALS told these professionals its deadline to respond was 23 October 2024. PALS received responses from Trust professionals about Miss Y’s complaint. PALS took no action after this and did not contact Miss Y with a response or any updates.

37. On 26 November 2024 Miss Y contacted PALS to chase up a response. PALS received more detail from Miss Y during a phone call and added additional components to her complaint including: • an unnecessary scan on her spine • Dr X video recording her, • her mistrust of the Trust, • her misdiagnosed kidney stone.

38. Miss Y’s complaints from 10 August were also included: • she was not given a second opinion • she had ongoing symptoms with no diagnosis, although this component was altered to say she was still waiting for speciality urology input and information on her care going forward.

39. We can see the contents of the complaint expanded on 26 November 2024. PALS continued to use reference number B and in all its investigative correspondence, PALS continued to quote the deadline as 23 October 2024. This suggests this was treated as the same ongoing complaint.

40. PALS did not contact Miss Y after 26 November 2024.

41. On 11 December 2024 Miss Y contacted PALS to ask for a complaint update. Miss Y received no response.

42. In February 2025 PALS undertook further investigation by contacting Trust professionals. In all correspondence, PALS stated reference number B, the deadline 23 October 2024, and that the complaint was ongoing from August 2024.

43. Miss Y received no communication from PALS. Miss Y then contacted us in July 2025 for our assistance. The Trust provided Miss Y with a complaint response on 6 August 2025.

44. PALS policy says it will address issues as quickly as possible and keep complainants informed of any progress and actions taken or proposed. It states it aims to acknowledge all referrals within one working day or within the next working day if received after 12pm.

45. It states timescales may vary. All complaints should be resolved as soon as possible, but always within a maximum of five working days. Trust PALS policy states if this time frame is exceeded, the complainant should be informed and given a new estimated completion date. We can see Miss Y’s complaint on 8 August 2024 was given reference number A.

46. We can see the Trust worked in line with PALS Policy to deal with the complaint promptly by asking the Matron to verbally discuss Miss Y’s complaints with her while she was an inpatient. We consider this was appropriate and in line with PALS Policy.

47. The Trust received Miss Y’s second complaint on 10 August 2024.The Trust did not acknowledge receipt of this email. This is not in line with PALS policy which states acknowledgement should be sent within one working day, or within the next working day if received after 12pm.

48. When Miss Y chased PALS for a response up in October 2024 her complaint was given reference number B with the target date 23 October 2024. It is clear the Trust classed this as a separate complaint to the one sent on 8 August 2024.

49. Miss Y added nothing new to her complaint, so we consider this was the same complaint as 10 August 2024. We consider 10 August 2024 as the start date for this complaint. Despite the complaint being altered in November 2024, Miss Y’s core issues remained the same and the same reference and target date was used until August 2025 when Miss Y received a response.

50. We can see Miss Y received no updates on her complaint in this time. This was not in line with PALS policy which states it should keep complainants informed. We can see the Trust did not act in line with guidance in dealing with the complaint in five working days. We can see PALS were aware of this as it referenced the target date in correspondence. However, we see no evidence of PALS informing Miss Y of the breach or providing an estimated completion date which was not in line with PALS policy.

51. We have seen an indication of failings in the time PALS took to respond to Miss Y’s concerns.

Impact

52. We have seen indications of failings in two areas. We can see the Trust wrongly identified Miss Y had a kidney stone measuring 1.8mm and it took too long to respond to her concerns

53. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative impact which the organisation has not put right.

54. We have done this and found we cannot link the misdiagnosed kidney stone to the impact Miss Y has claimed. We have found we can link the Trusts delayed complaint response to the impact Miss Y stated. We explain our findings below.

55. Miss Y told us when the Trust misdiagnosed the size of her kidney stone it did not treat her. She said when she had the correct diagnosis, she had lost trust in the NHS and had to get treatment elsewhere. Miss Y flew to Moldova on 16 August for private medical treatment and was given medication to help pass her kidney stone.

56. EAU guidance states renal stones less than 10mm in size should be managed conservatively. This involves watching the stone by taking regular images to check for stone growth and the development of new symptoms, an infection or an obstruction. An obstruction is when the stone blocks urine flow. Most stones remain stable and do not need intervention.

57. We consider if Miss Y had been correctly diagnosed with a 4.8mm kidney stone on 9 August, the Trust would have given Miss Y the same management plan to monitor the stone and not treat it in line with EAU guidance.

58. As Miss Y wanted treatment for her kidney stone, it is likely she would have remained dissatisfied with the Trust’s treatment plan and may have looked for treatment elsewhere. While we recognise the difficult experience Miss Y had getting the correct diagnosis, we cannot link this to her flying to Moldova to get treatment. For this reason, we will be taking no further action on this part of her complaint.

59. Miss Y told us the delays in the Trusts complaint process caused her significant stress. Miss Y has lost complete trust in PALS and worries if we had not got involved, she would have been completely dismissed.

60. Miss Y raised her concerns on 10 August 2024, and the Trust should have resolved them by 16 August 2024 in line with its PALS policy. Miss Y received her response from the Trust on 6 August 2025, a delay of 11 months and three weeks.

61. We can see a delay of this time is likely to have caused Miss Y stress in line with level 2 of our Severity of Injustice Scale. We also looked at other cases with a similar injustice.

62. We have shared our findings with the Trust. To resolve Miss Y’s complaint, the Trust have agreed to make improvements to its complaint process and pay Miss Y a financial remedy of £275 in recognition of her stress. The Trust’s resolution demonstrates understanding, learning and willingness to put complaints right in line with the NHS complaint standards. It also meets the outcome Miss Y wished to achieve by raising her complaint.

63. We consider the action the Trust has proposed will resolve this complaint for Miss Y. For this reason, we will not be taking further action on this complaint.

Conclusion

64. We can see the significant impact these issues have had on Miss Y. We were sorry to hear of her experience as an inpatient and her struggle to get a diagnosis. We hope our investigation has reassured Miss Y this did not impact her clinical outcome.

65. We can see the Trust has had a valuable opportunity to reflect on its complaint process. We thank Miss Y for bringing this complaint to us. We would also like to thank the Trust for its willingness to listen and put right Miss Y’s concerns.

1. We have carefully considered Miss Y’s complaint about University Hospitals Coventry and Warwickshire NHS Trust.

2. We have seen no indications of failings in the Trust giving Miss Y a second opinion. We can see indications of failings in the Trust’s diagnosis of the kidney stone, but we cannot link this to the impact Miss Y has claimed.

3. We have seen indications of failings in the time it took the Trust to respond to Miss Y’s complaint. The Trust has agreed to meet Miss Y’s desired outcomes. For this reason, we cannot take further action on the complaint.