Barts Health NHS Trust

5. Mr P complains about the care he received at Barts Health NHS Trust (the Trust) in March and April 2023.

6. He complains:

• the Trust failed to act appropriately following his allergic reaction to Amlodipine and continued to try and administer it. He says the Trust did not investigate this incident appropriately and denied it • the Trust inappropriately stopped him from filming and threatened to remove his wife from hospital by calling security • the Trust proposed a surgery that was not in his best interests • the Trust denied him a second opinion.

7. Mr P says he experienced an allergic reaction which led to him struggling to breathe. He says due to the Trusts’ failure to respond to this, he was almost administered this medication again. He says this was extremely distressing for him and he felt unsafe whilst under the care of the Trust.

8. He says the Trust’s failure to investigate the incident, and denial has caused further frustration and upset for him.

9. He says witnessing how the Trust treated his wife was distressing for him to witness. He says he felt intimidated which caused him to leave the hospital the next day.

10. Mr P says he almost had unnecessary surgery due to the Trust declining him a second opinion. Mr P says he had to leave the Trust and seek a second opinion, and this hospital did not recommend any surgery.

11. As outcomes to this complaint, Mr P would like an acknowledgement and apology from the Trust for what happened, and he would like the Trust to make service improvements. He would also like a financial remedy.

12. In March 2023, Mr P had suffered a fall from a ladder, and he was admitted to his local hospital.

13. He had fractured his spine. He was transferred to the Trust in March 2023 for fixation surgery.

14. During his admission, Mr P took Amlodipine (a medication to treat high blood pressure and angina), and shortly after his wife reported he was struggling to breathe and he had tongue swelling.

15. Mr P arranged a second opinion at another hospital and left the Trust. He was then managed conservatively, and he did not require surgery.

Allergic reaction to Amlodipine

19. 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.

20. Mr P complains that on 24 March 2023, following being administered Amlodipine (a medication used to treat high blood pressure and angina), he suffered with an allergic reaction. He says he became short of breath, had difficulty breathing, and his tongue became swollen. He says the Trust did not respond to his allergic reaction appropriately and still tried to administer Amlodipine.

21. Mr P told us the Trust denied he had an allergic reaction, stating he had not been prescribed any new medication. Mr P says he had been prescribed Amlodipine previously, but he had not been administered it until the morning he had an allergic reaction, which he says demonstrates the Trust did not investigate this properly.

22. Mr P’s medication administration charts record Mr P being administered Amlodipine on 22 March and 23 March 2023.

23. On 24 March 2023, the Trust gave Mr P Amlodipine. Shortly after, Mr P’s wife alerted the doctors saying Mr P could not breathe. The nurse took Mr P’s observations, and noted Mr P’s oxygen saturation was at 100%, and they advised him to cough out any phlegm.

24. Mr P’s wife then reported his tongue was swelling and that Mr P had been given a medication that morning that made his tongue swell. The nurse noted they assessed Mr P’s tongue, and there was no sign of swelling. The nurse took observations which came back normal. His National Early Warning Score (NEWS, a tool used to identify if a patient is deteriorating) was zero (the lowest score) .

25. The NICE guidelines say anaphylaxis (a severe allergic reaction), which includes difficulty breathing, usually happens less than one hour after drug exposure. As the administration charts show Mr P had Amlodipine already, a severe reaction is unlikely to happen that long afterwards.

26. Our adviser said in the videos of Mr P, he appears distressed but is able to talk in full sentences. They said patients who are suffering with respiratory distress would usually struggle to speak in full sentences. They also said it is unlikely to experience a severe allergic reaction to medication that had previously been administered. They said Mr P’s observations and oxygen rate would also indicate he was not in respiratory distress.

27. We understand Mr P believes he had an allergic reaction to Amlodipine. The records indicate Mr P did not have any signs of an allergic reaction. Based on the conflicting evidence we have, we cannot conclude he had an allergic reaction.

28. As the Trust did not think Mr P had an allergic reaction, it did not report this allergy on his records or refer him to the drug allergy service. As we have been unable to conclude he had an allergic reaction, we are unable to assess his concerns about how the Trust responded to his allergic reaction. We are also unable to criticise its investigation and response to the complaint, as the Trust’s response reflects what happened in the clinical records.

29. Mr P complains the Trust continued to try and administer Amlodipine following this incident.

30. NMC The Code says a nurse must respect, support and documenta person’s right to accept or refuse care and treatment.

31. Our adviser said as the Trust did not think Mr P had suffered an allergic reaction, the Trust was not required to stop prescribing the Amlodipine.

32. However, in line with NMC The Code, nursing staff should respect Mr P’s right to refuse care and treatment.

33. On 25 March 2023, Mr P said he was anxious about having a similar reaction and refused one of his medications. The nurse noted they reassured Mr P they would not give the medication if he does not want to take it.

34. On 28 March 2023, Mr P’s wife complained Mr P was still being given the medication. The nurse told Mr P that the medication was still prescribed on the drug chart which is why it was being offered, but Mr P can refuse the medication as he had been doing. They said they would inform the clinical team to review Mr P’s prescribed medications.

35. Later that day, Mr P’s clinical team discussed the medications with Mr P. They noted he was happy to continue taking Amlodipine.

36. On 29 March 2023, a nurse tried to give Mr P Amlodipine, and he refused to take this. The nurse said he should take it as his doctors advised. Mr P kept the medication but did not take it.

37. Later that day, the clinical team discontinued the prescription of Amlodipine, after Mr P told them he did not want to take it, and his wife said he was being harassed by the nurses to take this.

38. We are sorry Mr P felt the nursing staff repeatedly tried to give him Amlodipine, despite him not wanting this medication. Based on the evidence, as Mr P was prescribed Amlodipine, nursing staff offered him this medication. When he refused the medication, the nursing staff documented this and accepted this. This is in line with NMC The Code.

39. The nursing staff cannot discontinue medication prescribed by Mr P’s doctor, so they passed on Mr P’s concerns to his clinical team. The Trust discontinued Amlodipine, as agreed with him on 29 March 2023. We consider the nursing staff appropriately respected his decision to refuse Amlodipine until Mr P’s doctor stopped the prescription.

40. In summary, we not been able to say whether or not Mr P had an allergic reaction. We recognise Mr P recalls being unable to breathe and having a swollen tongue, and he says this was an allergic reaction. This conflicts with the evidence in his notes.

41. As we cannot say whether or not Mr P had an allergic reaction, we have been unable to consider his concerns about the Trust’s response to an allergic reaction. We consider, in line with the NMC guidance, the Trust respected his decision to refuse Amlodipine and discontinued this medication following further discussion with him. Therefore, we are not investigating this complaint further.

The Trust did not allow Mr P to film and threatened to remove his wife from hospital

42. Mr P complains, in April 2023, five members of staff came to his bedside, and during this discussion the Trust staff stopped Mr P’s wife from filming and threatened to remove her from hospital by calling security.

43. In Mr P’s diarised evidence, he said the staff member made them delete the video, with the threat of removing his wife from hospital by calling security. He described this as an attempt to intimidate and scare Mr P and his wife.

44. In the Trust’s response to the complaint, it said the meeting became challenging, and it found Mr P’s wife’s behaviour threatening. It also identified that recordings were made without the staff’s consent. It said the Trust do not tolerate threatening behaviour towards staff and staff are encouraged to involve the security team to ensure safety and assist in de-escalation.

45. The Trust’s policy on abuse and violence says unacceptable behaviour includes continuously difficult and challenging behaviour that creates an atmosphere that inhibits optimal care being delivered, excessive noise, for example loud or intrusive conversation or shouting, and the threat of violence.

46. It says at any stage of managing violence and or abuse, security can be contacted for help or advice. The Trust said staff must explain to the patient or visitor that their behaviour is unacceptable and outline the expected standards. It says the staff should report it to their manager or a senior member of staff.

47. The notes say Mr P was seen by members of the complex spine team, to establish Mr P’s onwards plan for treatment. The notes say Mr P and his wife interrupted one of the nurses, spoke over her and proceeded to speak in a loud volume while being asked not to shout.

48. The notes then go on to detail Mr P’s wife pointing at the staff and she called the staff liars, behaviour which the staff found threatening. The conversation ended and this was escalated to the senior nurse and the manager.

49. Shortly after, the senior nurse attempted to discuss Mr P’s discharge with him, as she was not involved in the previous discussion. They noted both Mr P and his wife were angry and raising their voices, and the senior nurse asked them repeatedly to stop.

50. The senior nurse noted Mr P’s wife was pointing her finger in her face, shouting and then brought up her phone to film her. The nurse noted they called security and asked Mr P’s wife to delete this video.

51. The senior nurse notified the team that Mr P’s wife had recorded the conversation earlier. The team noted Mr P and his wife did not ask for their permission before recording them.

52. The Trust’s notes of the events demonstrate they found Mr P’s wife’s behaviour unacceptable and threatening.

53. We appreciate Mr P says they were not acting inappropriately. He says this was a very upsetting conversation, and the senior nurse was not being empathetic, and was refusing to transfer Mr P to another hospital.

54. He says his wife speaks in a raised voice and uses hand gestures in expressing herself. Mr P says the senior nurse repeatedly told off his wife, for expressing her emotions during a distressing time. Mr P says calling security was not appropriate, and that the senior nurse was being intimidating by doing so.

55. We have conflicting evidence about this conversation, with the notes documenting the Trust’s staff felt Mr P and his wife’s behaviour was unacceptable and threatening, and Mr P disagreeing, and instead, he thinks the Trust were using the threat of security to intimidate them. As we were not there, and we have no other evidence to review, we have been unable to reach a conclusion about Mr P and his wife’s behaviour based on the conflicting version of events.

56. The Trust’s policy on abuse and violence supports staff to warn patients and visitors if they find any behaviour unacceptable or threatening, and to use security for assistance. In line with this policy, if the staff members felt Mr P and his wife’s behaviour was unacceptable and/or threatening, it was appropriate for them to warn Mr P and his wife about their behaviour and contact security.

57. We are unable to criticise the Trust for acting in line with its policy on abuse and violence, if the staff members did find Mr P’s wife behaviour unacceptable and threatening and it is not for us to say they did not feel this way.

58. The BMA guidance says patients can make recordings of consultations about the care, as a form of note taking for the patient. It does say patients should seek the agreement from the clinicians before recording and not do so covertly.

59. Mr P says his wife did point her camera at the nurse towards the end of the video, and the nurse made Mr P’s wife delete all of the video, including the earlier conversation.

60. The evidence shows Mr P’s wife did record the conversation, without seeking prior consent. When Mr P’s wife began filming the nurse, this conversation had escalated, and the nurse found this behaviour inappropriate.

61. In line with the BMA guidance, patients should make the clinicians aware about wanting to record the consultation, and it should not be done covertly.

62. On the Trust’s website, it says any recording should be done openly and honestly, and you cannot take anyone’s photo, including staff, without permission.

63. Although Mr P may have used the video as a form of note taking, we consider Mr P should have made the staff aware he wanted his wife to film and asked the staff for prior consent. Due to how the conversation had escalated, we understand why the nurse may have found the filming in her face inappropriate, and as she had not given consent, it was reasonable for her to ask for this to be deleted.

64. We are sorry if Mr P and his wife felt forced by the nurse to delete their videos and the nurse insisted on checking his wife’s phone and made her delete further videos. The Trust’s notes say Mr P was asked, not forced, to delete the video. As we were not there, and there is no further evidence for us to consider, we cannot establish whether this happened and whether the nurse acted appropriately.

65. We are sorry for how distressing this experience must have been for Mr P and his wife. We understand they felt intimidated by the Trust, and they disagree that they acted inappropriately. From our understanding, it seems this was an upsetting incident for both Mr P, his wife, and the Trust staff.

66. Due to conflicting evidence, as we were not present at the time, we have not been able to conclude whether Mr P and his wife’s behaviour was unacceptable, or whether the nurse inappropriately forced his wife to delete multiple videos.

67. We do think it was appropriate for Trust staff to warn Mr P and his wife about their behaviour, and call security, if they felt their behaviour was unacceptable or threatening, which is what is documented in Mr P’s notes. We also think it was reasonable for the Trust to ask Mr P and his wife to stop filming, since prior consent was not gained and how the conversation had escalation. Therefore, we are not going to investigate this further.

The Trust’s proposed surgery

68. Mr P complains the Trust proposed surgery that was not in his best interests and was not necessary in treating his condition. Mr P went on to manage his condition conservatively following getting a second opinion.

69. In March 2023, following a fall, Mr P was admitted to his local hospital. He was diagnosed with a lumbar fracture in his spine.

70. He was transferred from his local hospital to the Trust near the end of March 2023 for surgery for fracture fixation. The notes say he was transferred to the Trust for surgery due to his unstable facture.

71. Following his admission, his surgery for fracture fixation was scheduled. On the day of the surgery, the Trust cancelled his surgery, following Mr P being concerned about a potential allergic reaction.

72. The Trust decided to postpone his surgery, and explained he may not need surgery, and they may be able to manage his condition conservatively. The Trust planned to discuss this in a complex spine multi-disciplinary meeting (MDT) before proceeding with surgery.

73. The Trust discussed Mr B’s fracture in an MDT in March 2023 and decided the best outcome for treatment was fixation surgery, due to Mr P’s unstable fracture.

74. In April 2023, a consultant explained to Mr P and his wife that following the MDT meeting, the orthopaedic team felt surgical treatment was necessary, and went through this decision, showing them the imaging and explaining the outcomes. Mr P said he revoked his previous consent form and he wanted his operation in another hospital.

75. The notes say Mr P will arrange for a second opinion and possible transfer to another hospital. The next day, Mr P said again he was seeking a second opinion from another hospital. Mr P left hospital a few days later.

76. The RCOS guidelines say surgeons should ‘in conjunction with colleagues in the multidisciplinary healthcare team, construct and discuss with the patient a diagnostic and treatment plan based on clinical evidence and investigation findings. The risks and benefits of surgical intervention and the use of alternative forms of treatment should be considered carefully. Ensure that multidisciplinary team meetings are fully utilised both preoperatively and postoperatively.’

77. In line with the RCOS guidelines, the Trust arranged an MDT meeting to consider a treatment plan based on investigation finings. It postponed Mr P’s surgery to discuss and consider alternative forms of treatment, like conservative management. Following this discussion, the MDT decided the most appropriate treatment was surgical fixation.

78. The GMC guidance says in providing clinical care, a clinician must provide effective treatments based on the best available evidence.

79. Mr B suffered a fracture in his lower back, specifically in the third lumbar vertebra. This fracture affected three parts of his bone. There was also an extradural haematoma (a build up of blood) in the area around the fracture.

80. Our adviser said Mr P’s fracture was considered a potentially unstable fracture. They said the options of management would include conservative management with a suitable brace, bed rest for 6 to 12 weeks, and/or the offer of surgical fixation involving the insertion of rods and screws to allow internal splinting and fixation. They said the offer of surgical fixation was reasonable, and is accepted in clinical practice.

81. In line with the GMC guidelines, the Trust offered an effective treatment plan for Mr P based on the evidence it had, and following an MDT discussion with multiple surgeons.

82. We are sorry Mr P is unhappy with the treatment offered by the Trust. We have seen evidence the Trust proposed a treatment plan that is acceptable clinical practice for managing Mr P’s condition. The Trust considered the best available evidence and used a multidisciplinary team to construct a suitable treatment plan for Mr P, in line with the RCOS and the GMC guidelines. Therefore, we consider the Trust’s proposed surgery appropriate.

The Trust denied him a second opinion

83. Mr P complains the Trust denied him a second opinion. He said he requested a second opinion repeatedly which the Trust refused to do.

84. When the Trust cancelled Mr P’s scheduled surgery, the Trust explained this decision to Mr P, and that the consultant wanted to discuss his case in an MDT first. The notes indicate Mr P agreed to wait for the MDT.

85. In April 2023, Mr P wrote a letter to the Trust asking for a transfer to another hospital and withdrew his consent for surgery.

86. In April 2023, shortly after the MDT, the Trust met with Mr P and his wife and explained the MDT’s decision for surgery. At this discussion, this is the first time it is noted on his records that Mr P wanted his operation to be done at another hospital.

87. The consultant noted they respected this decision, and that Mr P will arrange a second opinion with a consultant at another hospital and arrange a possible transfer to another hospital.

88. The GMC guidance says a clinician must respect the patient’s right to seek a second opinion. In line with this, the consultant noted it respected this decision and would allow time for Mr P to pursue this.

89. In Mr P’s own diarised notes, he noted after this meeting, he rang his GP and requested an immediate transfer to another hospital.

90. The next day, a consultant spoke with Mr P again and noted he was currently seeking a second opinion from a consultant at another hospital, privately. The Trust noted to continue with the brace until a further decision was made.

91. Mr P complained to the Trust, saying it must arrange for his transfer to another hospital. We understand the Patient Advice and Liaison Service (PALS) discussed arranging the transfer to another hospital. Usually, when a patient wants a second opinion at another hospital, it is for a patient to ask their GP to refer them to a new hospital asking for a second opinion, which is what the clinical team advised Mr P.

92. A few days later, the Trust spoke with Mr P and his wife about pursuing treatment at the Trust or discharging him. It is noted Mr P asked for the transfer to another hospital be arranged as soon as possible. The Trust advised Mr P he would have to arrange a second opinion at his preferred hospital as previously discussed.

93. The Trust planned to discharge Mr P after confirming he wanted to continue with a second opinion from a different hospital, but by this time Mr P had left the hospital already. The Trust completed the discharge documents advising Mr P’s GP that Mr P had left and had decided to seek a second opinion at another hospital.

94. We are sorry Mr P feels he was denied a second opinion by the Trust. Based on Mr P’s records and Mr P’s diarised notes, Mr P said he was going to speak to his GP to arrange a second opinion at another hospital. We have not seen evidence in the notes that suggest Mr P was denied a second opinion. The Trust documented Mr P’s preference for a second opinion with a different hospital, and it would continue with conservative management until Mr P arranged this. We consider the Trust respected Mr P’s request for a second opinion, in line with the GMC guidelines. Therefore, we are not looking into this further.

1. We have carefully considered Mr P’s complaint about Barts Health NHS Trust (the Trust). We are sorry to hear about Mr P’s negative experience during his admission at the Trust, and that he felt unsafe, which led him to leave the hospital early.

2. Mr P complains the Trust failed to act appropriately following an allergic reaction to Amlodipine, and the Trust continued to try administering Amlodipine after this incident. We have not been able to conclude Mr P had an allergic reaction to Amlodipine, as such, we have not been able to reach a conclusion about what happened afterwards either. We are sorry for how disappointing this decision will be for Mr P.

3. Mr P complains the Trust inappropriately told them to stop filming a consultation and threatened removing his wife from hospital. We have seen evidence the Trust staff felt Mr P and his wife’s behaviour was unacceptable, and it was appropriate for Trust staff to warn Mr P and his wife and call security, in line with the Trust’s local policy. We also consider it was appropriate for the Trust to ask Mr P and his wife to stop filming and delete the videos it had taken without obtaining consent. Therefore, we are not looking into this further.

4. Mr P complains the Trust denied him a second opinion, and proposed surgery that was not in his best interests. We have seen evidence the Trust respected Mr P’s decision to seek a second opinion, and that the proposed surgery was clinically appropriate. We are not looking into this complaint any further.