Frimley Health NHS Foundation Trust

6. Ms P complains about the following aspects of care and treatment she received from Frimley Health NHS Foundation Trust (the Trust) between January 2022 and June 2024. She specifically says:

• there was a delay in having an appointment with the colorectal nursing team, despite her being referred to the team in February 2022 she did not have an appointment until October 2022 • the Trust did not provide her with an appointment between October 2022 and February 2024 despite her advising the Trust she would like a neurogastroenterology referral to Trust B • the Trust agreed to send a referral in February 2024 but then referral was not processed until June 2024. Ms P also adds when the referral was sent it was inadequate, out of date and contained incorrect information • the Trust told her it had sent a second referral in September 2024 however, this was never sent as the receiving Trust confirmed it did not receive the referral.

7. Ms P says if the referrals had been correctly sent in late 2022, she could now be on appropriate treatment and have a diagnosis. Ms P feels if the referrals had been sent appropriately Trust B would have been taking on out of area patients but due to the delay she now cannot be seen by Trust B.

8. Ms P says her health has deteriorated significantly in which she is in pain on a daily basis and is woken at various times in the night due to the pain. She says she cannot plan appointments due to being unable to leave the home. She says her condition is very draining both mentally and physically and has left her unable to look after herself or her home.

9. Ms P says she is looking for service improvements and a financial remedy.

10. Ms P is in her eighties and suffers from chronic constipation.

11. On 9 February 2022, the Trust referred Ms P to its rectal irrigation clinic.

12. On 12 October 2022, Ms P had her first appointment with the rectal irrigation clinic.

13. Ms P’s next appointment was on 12 February 2024, where Ms P expressed she would like a further neurogastroenterology referral to be made. The Trust agree to this however, the referral was not sent until June 2024. This referral was rejected due to the Trust already having a long waiting list and Ms P being an out of area patient.

14. Ms P therefore requested a further referral to be sent to another trust (Trust C) on 27 September 2024. The Trust said Trust C rejected this as it was no longer seeing patients with this symptomology.

Appointment

18. Ms P says she was referred to the colorectal nursing team in February 2022 but did not have her first appointment with this clinic until October 2022.

19. We are sorry to hear of this delay and understand how frustrating this must have been for Ms P.

20. The Trust says in its response Ms P’s outpatient appointment with the colorectal nursing team was on 12 October 2022.

21. Ms P’s medical records show during the appointment on 12 October 2022, the Trust ‘apologised for the delay and was sorry she had to chase this appointment today’.

22. Our adviser says there is no guidance on how quickly a patient should be seen by this type of service as it would depend on the resources each individual trust has access to. However, they added a delay of eight months is a long time and not to be expected.

23. We therefore consider this to be a failing and we will consider the impact of this on Ms P later in our report.

Delay

24. Ms P has raised concerns she received no care or appointments from the Trust between October 2022 and February 2024.

25. This is a considerable length of time to go without any appointments or treatment from the Trust. Therefore, we understand Ms P’s reason to raise this as a concern.

26. The Trust says Ms P has been reviewed and assessed by different teams throughout her care under the Trust since 2021.

27. Following Ms P’s appointment in October 2022 we understand, ‘Lots of options were discussed today, so she will try the irrigation first’. The next information we have is from an appointment in February 2024. Therefore, we agree Ms P did not have an appointment between October 2022 and February 2024. We recognise Ms P says only two options were discussed, with further discussion about different ways of carrying one of these options out.

28. Ms P’s medical records show following her rectal irrigation clinic appointment, the plan discussed was as follows,

‘1. To trial the Qufora hand pump 2. Contact details given 3. SOS.’

29. This is evidenced within Ms P’s medical records which say the plan was communicated with Ms P during the appointment and a copy of the clinic letter was also sent to Ms P and her GP. Ms P says she has no recollection of this.

30. The Trust gave Ms P contact details and therefore was relying on her contact it before making an appointment. We understand from the medical records following Ms P’s appointment in October 2022 the Trust had effectively discharged her and had no plan to see her unless requested by Ms P.

31. We do not consider there is any failing here as the Trust had communicated it had no plan to see Ms P unless she needed an appointment.

Referral – February 2024

32. Ms P has raised concerns that following the Trust agreeing to send a referral in February 2024, the referral was not sent until June 2024. When the referral was sent it was inadequate, out of date and contained incorrect information.

33. We are sorry to hear Ms P had to wait four months for the Trust to process a referral.

34. The Trust says it agreed to send a referral to Trust B during Ms P’s appointment on 12 February 2024 but it did not send the referral until 6 June 2024.

35. Ms P’s medical records from her appointment on 12 February 2024 says, ‘Miss P had asked to be referred to a further neuro gastroenterologist which I can certainly do if she feels that would be of benefit’.

36. The GMC guidance says, ‘refer a patient to another suitably qualified practitioner when this serves their needs.’

37. We would consider this is confirmation the Trust would send the referral and it is understandable Ms P would expect a referral to be sent following this appointment.

38. We have been unable to find any evidence to suggest the Trust sent this referral after this appointment in February 2024. We understand the referral was sent in June 2024 following contact from Ms P chasing a response.

39. Our adviser says there is no guidance on how quickly a referral should be sent however, it would be expected this would be within a few weeks.

40. We can see from the Trust’s response it says the referral was delayed as the doctor who saw Ms P in February 2024 was away from the Trust. However, there are no notes to suggest when the doctor went away and how long this was for.

41. Our adviser says despite the doctor being away from the Trust it would be expected that work would be completed before they left or this would be passed to another colleague to complete.

42. We have not seen any reason to suggest the referral should not have been sent shortly after the appointment in February 2024. The referral was delayed until June 2024, four months later. We consider this a failing and we will consider the impact of this later in our report.

43. With regards to the referral containing inadequate, out of date and incorrect information, the GMC guidance says,

‘You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must: a share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers.’

44. We understand due to the delay in sending the referral between February and June 2024, some information may have changed such as medication. However, our adviser says this would have had no impact on the referral being accepted or not.

45. We can see the referral contained a brief summary of Ms P’s investigations and issues. Our adviser says the referral is appropriate and provides a brief overview of the issues which would enable the referring clinic to investigate once they had accepted the referral and provided an appointment.

46. We understand Ms P’s disappointment with the delay in sending the referral, which we agree is a failing. We do not consider once the referral was sent that it was inappropriate, out of date or contained incorrect information. We do not consider there is a failing in this element of the complaint.

47. We hope this offers Ms P some reassurance that the referral was appropriate despite it being sent four months late.

Referral - September 2024

48. Ms P has raised concerns as the Trust agreed to send a further referral in September 2024 however, this was not sent as the receiving Trust (Trust C) confirmed it did not receive the referral.

49. Ms P says the Trust informed her it had sent a second referral in September 2024 however, when she contacted Trust C it had not received a referral.

50. We are sorry to hear Ms P was provided with information which did not appear to be true. We understand how frustrating this would have been for her.

51. The Trust says it wrote to Ms P ‘on the 27 September 2024, to confirm [we] had made a further referral to [Trust C] at your request however noted they did not have the capacity to see you with your symptomatology’.

52. From our understanding the first referral in June 2024 was sent to Trust B and this referral in September 2024 was to be sent to Trust C. The Trust says it received a response to this referral which suggests a referral was sent.

53. Ms P’s medical records show the Trust sent a letter dated 27 September 2024 to explain what the Trust had done so far with regards to care and treatment and what its next steps were. This included its referrals to both Trust B and Trust C.

54. We can see the Trust wrote to Ms P following this saying, ‘However, you did ask for a further referral to be made (as your GP was unable to do this) to [Trust C] which I did; they felt they did not have the capacity to see you with this symptomatology’.

55. We have also spoken to Trust C who have been unable to locate a received referral or any letter it sent about why it could not see Ms P at this time.

56. Based on the evidence we have available to us, we consider the referral to Trust C was either not sent or not sent correctly as Trust C did not receive this referral. We consider this is a failing and we will consider the impact of this next.

Impact

57. We will now consider the impact of the failings with the delay in an appointment with the colorectal nursing team and delays with the referrals in February and September 2024.

58. Ms P says due to the delays her condition has deteriorated significantly, and she is in pain on a daily basis. She adds this is affecting her ability to lead a normal life due to worries about leaving the home. She also says her condition is draining on her both mentally and physically. We are saddened to hear Ms P’s feels she can barely exist. We recognise how debilitating, exhausting and painful her condition is.

59. Ms P has been suffering with chronic constipation for a number of years. She told us the life she is left with has no joy left in it.

60. Our adviser says a delay of eight months in being seen by the colorectal team and four months with a referral being sent would have had no impact on her physical symptoms and she would have seen little change in her symptoms during this time period. In saying this we recognise her symptoms were already causing daily issues in her life, but we do not consider the delays made her symptoms worse during this period. We recognise Ms P says her condition is worse now than it has ever been.

61. However, we consider this delay had a psychological impact on Ms P. She has been suffering from her physical symptoms every day not knowing that her referrals have been delayed or that there would be a delay in being seen by the colorectal nursing team. The issues with the referrals mean Ms P has not been seen by either of these Trusts (B or C), which has left her not knowing whether further tests, investigations or medication could have been provided which would be helping her by now.

62. With regards to the delays, we consider the Trust has treated and investigated Ms P’s symptoms in line with the BSG guidance.

63. Ms P had already received medication and psychological treatment in terms of laxatives and CBT (cognitive behavioural therapy) in line with the BSG guidance. Ms P had also been offered irrigation which was unable to go ahead as she had tried it before with little success. It was not possible to arrange a transit study (a test of the movement through the large intestine) to investigate the constipation further because she could not come off her laxatives.

64. The Trust has also offered her a stoma (a surgically created opening on the abdomen that allows waste to leave the body when normal pathways are unavailable) which she was not keen on this idea due to its risks and complications.

65. We consider if the Trust had sent the referrals appropriately in February and September 2024 this could have been helpful for Ms P at understanding everything has been done to help her.

66. We cannot say Ms P would have had a diagnosis and would be receiving treatment if the referrals had been sent appropriately, as the Trust has treated her in line with relevant guidance. This does not resolve the psychological impact on Ms P in terms of not having these second opinions. We consider she will always be left wondering if enough has been done to try and diagnose and treat her.

67. Also, Ms P has said due to the delays she can now no longer be seen by Trust B as it no longer accepts patients living out of its area.

68. Ms P has the right to be referred to a hospital of her choice. Therefore, we do not consider the Trust delaying her referral has led to her not being able to be seen by Trust B. Ms P may need to speak with her GP about making another referral to Trust B.

1. Ms P has raised concerns about a delay in having an appointment with the Trust’s colorectal nursing team and delays with referrals sent in February 2024 and September 2024. We consider there are failings in these matters which has had a psychological impact on Ms P with having to wait for appointments and not knowing if other treatment is available to her.

2. Ms P has also raised concerns about the Trust not providing her with an appointment between October 2022 and February 2024. We consider there has been no failing here as the Trust had arranged to see Ms P on an ‘as needed’ basis.

3. It is therefore likely that we will partly uphold the complaint overall.

4. We are proposing to make recommendations based on what we have seen so far.

5. This report may be difficult for Ms P to read as we recognise how long she has been suffering with her symptoms. We are saddened to learn she feels she leads a miserable existence. We hope our report offers her some reassurances about her care due to the failings we have identified.

69. 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.

70. 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).

71. To support our thinking, we also look at similar complaints we have upheld and the types of remedy – we do this through precedent checks of our ‘typology of injustice’.

72. The typology is a record of specific amounts we have recommended in the past with a detail of the injustice and complaint. They represent the sort of principles the Ombudsman considers should apply to investigations where financial remedy is appropriate.

73. 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.

74. We do not have standard amounts that we suggest for specific failings as these may impact the person affected differently in different circumstances. We consider the individual facts of a case in deciding what level of financial payment is appropriate to recommend.

75. 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.

76. We categorise injustice types by four main categories. These are emotional, material, physiological, and bereavement.

77. We may our scale in conjunction with our typology to cross-reference the amounts we have decided.

78. In bringing her complaint to us, Ms P is seeking service improvements and a financial remedy.

79. We have identified failings in relation to a delay with an appointment with the colorectal nursing team, a delay with sending a referral in February 2024 and no evidence of a further referral being sent in September 2024. We consider this led to Ms P experiencing distress and thinking more could be done to help her and her symptoms.

80. We identify this as an emotional injustice. Our scale describes a level two emotional injustice as, ‘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’.

81. Ms P’s condition already caused her pain amongst other symptoms. What we have focussed on it the additional emotional impact caused by the Trust’s delays and missed referrals. We consider this fits the description of a level two injustice.

82. With that in mind, we are proposing to recommend that following our final report the Trust:

• writes to Ms P within one month of our final report to acknowledge the failings we have identified and apologise for the impact of the failings we have identified and the impact this has had on Ms P • pays Ms P £150 within one month of our final report in recognition of the distress caused to her with the delays in the appointments and referrals and for her thinking more could be done to help her • explains what action it will take, or has taken, to address these failings within three months of our final report. It should do this in the form of an action plan which should be shared with us, Ms P, and CQC (Care Quality Commission) and NHS England.

83. We will ask the Trust to send us evidence it has completed all of 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.