Manchester University NHS Foundation Trust

4. Mr O complains the Trust:

• did not identify and repair multiple hernias during surgery in December 2024 • clinicians operated on a different hernia - without his consent - during surgery in December • staff member wrongly told him that a mesh had been used during surgery • consultant refused to review his photographic evidence during the February 2025 consultation • incorrectly said his complaint was outside of the Patient Safety Incident Response Framework (PSIRF), avoiding the formal investigation it required • did not fully address his complaint and gave contradictory responses, he explains it wrongly said twice in its complaint response the hernias were a recurrence.

5. As a result of the Trust’s failure to repair the other hernias, Mr O says he had to have a second invasive surgery, causing him unnecessary pain, scarring, risks of complication and prolonged recovery. He says he had to miss planned work events which undermined his role and reputation during his probation period, resulting in him having to quit his job. This caused him a loss of earnings.

6. He says the incorrect information about the mesh, delayed the escalation of his persistent hernia and left him symptomatic for longer.

7. Mr O says the Trust’s actions/lack of actions caused a detrimental effect to his mental health, emotional distress and loss of trust in the NHS.

8. Mr O would like a financial payment.

Hernia operation

14. Mr O complains the Trust:

• did not identify and repair multiple hernias during surgery in December 2024 • clinicians operated on a different hernia - without his consent - during the surgery.

15. In early November 2024, Mr O had an appointment with the Trust’s Consultant General Surgeon. He says they examined him and identified one hernia (middle hernia).

16. In early December, the Trust carried out surgery. However, he complains it identified and repaired a different hernia (lower hernia) – near his navel.

17. Mr O says the hernias were close enough to each other that two separate clinicians, using physical examination alone, each found a different one and confused it as the presenting complaint.

18. Mr O says he had an ultrasound scan (USS) in early March 2025 which confirmed he had two additional hernias (middle and upper hernias) containing adipose tissue (connective tissue consisting mainly of fat cells) and non-reducible in size. He says they were present at the time of the USS and believes they had been there before. He believes the Trust’s justification for not looking further at the time of the surgery in December 2024 is undermined by its own consultant’s findings.

19. Within the Trust’s complaint response (May 2025) it said the decision to proceed with surgery was based on the identification of a single hernia. It said this was confirmed during a consultation with its Consultant General Surgeon in early November 2024 and again during the preoperative assessment on the day of Mr O’s surgery (December). It said at the time, it asked him to cough and strain, which helped to pinpoint and mark the site of concern. The Trust said no additional lumps or clinically detectable defects were found during the examination.

20. It said it made an incision directly over the marked area, where it identified and repaired a small hernia defect.

21. As a clear defect was found and addressed, the Trust said there was no clinical indication to explore more extensively. In keeping with good surgical practice, and Mr O’s preferences regarding scar size and cosmetic outcome, a focused and minimally invasive approach was chosen to effectively treat the confirmed hernia without unnecessary exploration.

22. The Trust said two small (less than 5mm) defects were later found higher up. The later USS scan found a second defect at 1mm which would not be clinically apparent. Due to the size of the two defects and location, they were not detectable on physical examination and would not be visible during surgery without much broader dissection.

23. Our adviser said there is no clinically relevant evidence to show that Mr O had multiple hernias at the time of the surgery in December 2024. The medical records show:

• The GP referral references a paraumbilical hernia only (this is where internal tissue or an organ protrudes through a weakened area around the navel).

• The outpatient assessment (November 2024) by a surgeon at the Trust records that Mr O said, ‘he had noticed a paraumbilical hernia when he was at the gym doing crunches.’ The surgeon examined Mr O and describes a paraumbilical hernia only.

• The assessment on the day of Mr O’s surgery refers to the paraumbilical hernia only as being the area that needs to be repaired. This is reflected in the consent form which only describes a repair of a paraumbilical hernia.

• There was no indication that a scan was indicated to further assess the hernia that was clinically evident.

24. In terms of clinical guidelines/standards, our adviser explains there is no mandate that all patients must have a pre-operative scan (either USS or a computed tomography (CT) scan) to look for occult defects (where a hernia does not produce a visible bulge).

25. The relevant guidance is the BJS Society: Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. This says:

‘It is recommended that umbilical or epigastric hernias are diagnosed by clinical examination alone. Imaging by ultrasound examination or CT can be considered in case of doubt.’

26. Our adviser said there is no guidance to suggest the surgeon should have explored for other hernias. From a practical point, this would involve making a bigger incision. In theory there can be occult defects throughout the abdominal wall and therefore only a full abdominal incision (from the top to the bottom of the abdomen) would rule out an occult hernia. This would not be acceptable to any patient or any surgeon.

27. Our adviser said the Trust performed a standard operation. It identified a hernia and fixed it. There were no obvious other defects in the immediate vicinity of the surgical incision.

28. In early February 2025, Mr O had a consultation with the surgeon who carried out the operation in December 2024. Mr O felt the hernia was still present. The surgeon referred him for a USS scan to assess the presence of the hernia, its size and distance from the navel.

29. In March 2025, the Trust carried out a USS scan on Mr O’s abdomen and identified two further hernias – epigastric. Epigastric hernias occur in the upper midline of the abdomen whereas paraumbilical hernias appear around the navel.

30. In early April, Mr O was seen by the same consultant he saw in November 2024, who after seeing the scans and feeling his abdomen, recorded there were two small epigastric hernias above where he had the paraumbilical hernia repair. The consultant then listed him for a further hernia repair.

31. Our adviser said there is no evidence the Trust operated on a different hernia than it identified in the November 2024 consultation. All the communication references a paraumbilical hernia which the Trust fixed.

32. We recognise Mr O’s concerns on whether the Trust failed to identify and repair multiple hernias during his surgery and obtained consent on the hernia it repaired.

33. There is no evidence to show the Trust operated on a different hernia than it identified in the pre-operation consultation and which Mr O consented to. Three different clinicians identified a paraumbilical hernia, prior to the operation in December 2024. There is no evidence Mr O queried the location of the identified hernia prior to the operation in December. The hernias the Trust later identified (March 2025) were epigastric hernias, which are in a different location from a paraumbilical hernia.

Mesh

34. Mr O complains a Trust staff member wrongly told him that a mesh had been used during surgery.

35. He explains that following discharge in December 2024, he contacted the surgical ward because he believed his surgery had failed, the hernia was visibly still present. He says a member of staff read from his notes over the phone and told him that ‘less than 1cm of mesh’ had been used in the area.

36. Mr O says this information was wrong. No mesh had been used. He says this was confirmed in a consultation with the Trust’s Consultant Upper Gastrointestinal (UGI) and General Surgeon in February 2025.

37. The Trust did not respond to this complaint.

38. The medical records show the Trust did not use any mesh during Mr O’s surgery in December 2024. The Trust repaired his paraumbilical hernia with sutures.

39. The discharge summary and hospital plan recorded absorbable sutures used that do not require removal.

40. We cannot see evidence within the medical notes of the telephone conversation Mr O complains about. Our adviser suggested the mention of ‘less than 1cm’ would have referenced the ‘less than 1cm defect’ (as detailed in the operation notes) which justifies no mesh being used.

41. The medical records show that during the consultation between Mr O and the surgeon in early February 2025, they confirmed no mesh was used. They said:

‘we found a split in the muscle which was repaired with suture and not mesh.’

42. We are not dismissing Mr O’s recollection of events or the impact he says this caused. In situations like this, it is often difficult to establish what happened, especially when there is no other compelling evidence for example call recordings or correspondence. We are not saying this conversation did not happen, but there is insufficient evidence to say it did. We cannot say there is an indication of failing on the part of the Trust.

February 2025 consultation

43. Mr O complains the consultant refused to review his photographic evidence during the February 2025 consultation.

44. There is no evidence Mr O brought this complaint to the Trust. He did not raise this in his communication to the Trust in mid-April 2025, or within his emails in late June. There is also no evidence the Trust responded to this complaint either.

45. Although Mr O had opportunity to do so, there is no evidence he raised this complaint with the Trust.

46. In health cases, section 4(4) and (5) of the HSC Act 1993 prevents us from conducting an investigation unless we are satisfied the complaints process has been used and exhausted, or it was not reasonable to expect the complainant to have done so.

47. In line with the HSC Act, we cannot investigate this aspect of Mr O’s complaint. This is because there is no evidence he raised this with the Trust and gave it opportunity to respond. His complaint is not yet ready for us. We cannot progress this complaint to detailed investigation.

48. The HSC Act 1993 (Section 9(4)) also says we cannot accept a complaint if it is made more than a year after the day on which the person aggrieved first had notice of the matters in the complaint, unless we consider it reasonable to do so.

49. Even if Mr O raised this with the Trust now and then brought his complaint to us, it is likely we could not investigate. This is because the complaint is outside of the statutory time limit time for us to investigate, in line with the HSC Act 1993.

Patient Safety Incident Response Framework (PSIRF)

50. Mr O complains the Trust incorrectly said his complaint was outside of the PSIRF, avoiding the formal investigation it required.

51. He says he raised the term ‘wrong site surgery’ with the Trust on multiple occasions across the complaint process. He says by the Trust refusing to acknowledge or engage with the term, the Trust avoided triggering the framework the term would have engaged.

52. The Trust, within its August 2025 complaint response, said in August 2022, the NHS England published the new PSIRF. It said the Trust fully investigated Mr O’s complaint under its complaint policy. The clinical team involved in his care appropriately managed his treatment and care. Therefore, it said no further investigation would be undertaken, as it does not fall within the scope of PSIRF.

53. The relevant guidance is NHS England: Patient safety incident response framework and supporting guidance. This says:

‘Patient safety incidents are unintended or unexpected events (including omissions) in healthcare that could have or did harm one or more patients.’

54. Our adviser confirmed Mr O’s complaint falls outside the scope of PSIRF. This was not a case of wrong site surgery. As explained earlier within this decision, all the pre-operative correspondence, and particularly the GP referral, mentions a paraumbilical hernia and the operation note confirms that a paraumbilical hernia was operated on. This case does not fall into the PSIRF category.

55. We acknowledge Mr O questioning whether his complaint should have been dealt with under the PSIRF. Informed by clinical advice, we consider his complaint falls outside the scope of PSIRF. We cannot say the Trust did anything wrong here.

Complaint handling

56. Mr O complains the Trust did not fully address his complaint and gave contradictory responses. He says the Trust:

• wrongly said twice in its complaint responses that the later identified hernias were a recurrence • did not respond to his complaint about being told it used mesh to repair his hernia in December 2024 • did not explain within its complaint responses the contradiction between the two surgeons when one said, ‘he could not convincingly feel or see the hernia’ (February 2025 consultation) and the other surgeon later said, ‘you can clearly feel the small epigastric hernia above where he has had a paraumbilical hernia repair.’ (April 2025 consultation).

57. The relevant guidance is Regulations 2009. This explains the ‘responsible body’ (in this case the Trust), after completing the investigation, must send the complainant in writing a response with ‘an explanation of how the complaint has been considered’…. and conclusions reached, including where the responsible body considers ‘that remedial action is needed’.

58. In mid-April 2025, Mr O sent an email of complaint to the Trust. It responded in late May. We have considered the relevant documentation. This shows the Trust responded to the complaints raised by Mr O in his April email.

59. Mr O responded to the Trust’s complaint response in late June. Within his email, he did not raise concerns that it did not address his complaint. Instead, he requested a full investigation into the surgical failings, PALS handling of his complaint, a review under the NHS Serious Incident framework and a financial remedy.

60. In a later email a few days later, Mr O explained about a conversation he had with a ward nurse following his discharge who said mesh was used during the repair of the hernia. Mr O, however, makes no reference to the complaints about the contradictions between the two surgeons. Within this email, Mr O said twice he did not want any further dialogue with the Trust and was instead requesting financial redress.

61. The Trust sent Mr O its final response in late August 2025 and addressed the comments in his email dated late June. Although, it did not comment about the conversation concerning the mesh (raised in his further email in late June), he told the Trust twice in this email that he did not want any further dialogue with it. We therefore cannot be critical of the Trust for not responding to him on this matter.

62. We consider that in the main the Trust provided a response to his complaints in line with Regulations 2009. This is because its responses showed ‘an explanation of how the complaint has been considered’…. and conclusions reached. There is no indication of a failing.

63. However, we consider the Trust incorrectly said within its complaint responses the hernias it identified later appeared to be a recurrence.

64. There is no evidence in the medical records that it considered Mr O had a recurrence of the hernias following his surgery in December 2024.

65. During Mr O’s consultation with the surgeon in early April 2025, the surgeon explained to him that ‘he likely has had multiple defects from the start..’ and this was confirmed in a clinical letter to Mr O. The Trust then listed him for an epigastric hernia repair.

66. Our adviser said the second operation the Trust carried out was not to repair a recurrence of the first hernia. It was to fix two small separate defects in the supra-umbilical epigastric area which had been identified. This is confirmed in the medical notes.

‘day case epigastric hernia repair. Two small hernias found and suture repair.’

67. We therefore consider the Trust’s complaint response about recurrence did not accurately reflect the medical records. This is not in line with NHS complaint standards: Summary of expectations, which says conclusions reached when responding to a complaint should be ‘based on established fact.’

68. We understand this response caused Mr O distress at an already difficult time.

Based on our Principles, where there have been failings leading to an injustice (distress), the public organisation (the Trust in this case) should try to offer a remedy that returns the complainant to the position they would have been in, if the failings had not happened.

69. An appropriate range of remedies include:

• an apology, explanation and acknowledgement of responsibility • remedial action, i.e. service improvements to minimise the risk of this happening again • financial remedy.

70. Mr O explained to us that he does not want an apology or other remedial action. He is seeking a financial redress only.

71. Mr O’s request for a financial remedy relates to the complaint as a whole, which includes the more serious claimed impact regarding clinical matters. If we look at complaint handling in isolation, we do not consider a financial remedy is proportionate. This is because Mr O already knew (from the consultation in April 2025) the additional hernias were not a recurrence by the time the Trust sent its first complaint response. We therefore consider the claimed impact would be level one on our severity of injustice scale. This is because of the low impact injustice and where the effect on Mr O is of a short duration with no other adverse effects.

72. In these situations, we usually consider an apology is an appropriate remedy. However, as Mr O does not want an apology (just financial redress) and would not accept one if offered, no further remedy is required. We cannot progress this complaint any further as we cannot achieve his desired outcome (financial redress).

73. We are sorry to learn of Mr O’s complaint about the Trust and the impact this had on him. Our primary investigation decision is not made without recognition of the impact these events have had on him, and we are sorry if our decision causes any further upset. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. We are sorry to learn of Mr O’s experiences with the Trust. We acknowledge the difficult circumstances around this complaint, and the impact this has had. We recognise this was, and continues to be, a difficult time for him.

2. We have carefully considered the complaint about the Trust. Having done so, and for the reasons set out in this statement, we have decided not to investigate this complaint further.

3. Our decision is not made without recognition of the distressing circumstances around the events.