Barts Health NHS Trust

6. Mr Q complains about aspects of care and treatment his newborn son, M, received from Barts Health NHS Trust (the Trust) between 21 May and 10 June 2025. He specifically says it failed to: • carry out the consented ablation procedure • gain consent for the dilation procedure it performed • involve other specialists (renal) in a timely manner for his son’s condition • keep his son in hospital when his blood levels were not safe.

7. He also says Trust staff threatened him with safeguarding action, and he says its overall communication with him was poor.

8. He also says the medical records contain serious inaccuracies and false allegations about his behaviour.

9. Mr Q says the failings have caused severe emotional distress, a loss of trust in NHS care, and potential long-term risks to his son’s health.

10. By bringing this complaint to us, Mr Q hopes to understand what happened for the failings to occur. He would also like the Trust to: • apologise for the failings and acknowledge the impact they had on him and his son • make service improvements to prevent others having the same experience • add a note on his son’s medical records to evidence that he disagrees with some of the statements about his ‘aggressive’ behaviour.

11. M was born on 21 May 2025 with a blockage in the tube that carries urine out of his bladder (posterior urethral valve - PUV). This meant his bladder was under a lot of pressure and stopped urine from draining properly from his kidneys, causing them to swell. This put strain on both his bladder and kidneys (hydronephrosis and bladder diverticula).

12. Due to M’s condition, he needed specialist care and close monitoring. Whilst in hospital he was also diagnosed with several serious kidney and urinary problems. These included urine flowing backwards from his bladder towards his kidneys (vesicoureteral reflux) and a swollen ureter (hydroureter) due to poor drainage of urine.

13. Blood tests showed that his body was not clearing waste properly, with raised urea levels, and he was found to have longterm kidney damage (chronic renal failure). He also developed an imbalance in his body’s chemistry (metabolic acidosis), meaning his body had become too acidic because his kidneys were not working well enough.

14. On 30 May, the Trust performed a cystoscopy and ablation of PUV. Ablation is a procedure done to treat the condition affecting the urinary system and involves disruption of the valves.

15. M was discharged home on 10 June 2025.

Pre-operative checks

19. Mr Q says the theatre notes confirm the pre-operative checklist was not completed before his son’s transfer to theatre on 30 May 2025. He says this is a breach of standard surgical safety protocol and could have had an impact on the care provided to his son.

20. WHO ‘Surgical Safety Checklist’ was developed with an aim to decrease errors and adverse events and increase teamwork and communication in surgery. NHSE ‘NatSSIPS’ built on this and set out broader principles of safe practice including a series of standardised safety checks.

21. The records state that the pre-operative checklist was not completed before M’s transfer to theatre.

22. Our adviser explained that there are a number of steps with a check list. The first one occurring on the ward prior to leaving for theatre, another on arrival into the anaesthetic room, and a third comprehensive check on arrival into theatre.

23. Although not completed prior to transfer to theatre, our adviser told us that the NATSIPP document in the notes was completed on arrival to theatre and prior to the surgery being done. Therefore, we consider the necessary checks had been completed in line with the mandatory WHO ‘Surgical Safety Checklist’ and NHSE ‘NatSSIPS’.

24. We recognise the worry this caused Mr Q when he saw this written in the medical records. We hope it provides him with assurance to know that this was completed and there was no impact on his son.

Consent, procedure, and specialist involvement

25. Mr Q says the Trust did not carry out the ablation procedure he consented to on his son’s behalf or gain the required consent for the dilation procedure it performed. He says this has caused worry that the procedure was not properly done and had a direct impact on his son’s renal outcome.

26. The Royal College of Surgeons guidance on consent states that consent to treatment must be confirmed in writing and given voluntarily by a person who has capacity and who has been given the appropriate information to make this decision.

27. EAU ‘Guidelines on Paediatric Urology’ states that, once a baby with PUV is stabilised, the next step is to perform an endoscopic valve ablation provided the urethra is accessible with available equipment.

28. Our adviser explained that the Trust gained valid consent for the valve ablation. The aim was not just to improve flow a little, but to clear the obstruction as fully as possible, to protect kidney function and bladder development. They explained that this step was always necessary and the decision to undertake this procedure was in line with EAU ‘Guidelines on Paediatric Urology’.

29. Our adviser also explained that it is standard practice to use small, graded dilators to gently enlarge the opening at the tip of the penis and urethra to allow passage of an appropriately sized paediatric cystoscope or resectoscope (camera with a knife to cut) for standard endoscopic valve ablation. This routine technical step should be carried out cautiously and in proportion to the baby’s size. Additionally, that it is also standard practice to arrange a repeat cystoscopy at around six weeks to check if there are any remaining valve leaflets still causing an obstruction.

30. The records indicate that the normal equipment was not functioning properly but that ‘a urethral dilator was passed through, after which the valves were well disrupted and there was a good urinary stream’.

31. Our adviser confirms that urethral dilation is frequently needed in cystoscopy as the size of the urethra is too small for the camera to pass safely. As the normal equipment was not working properly, this was done to progress care as leaving M untreated would increase the risk of renal failure and bladder dysfunction. They explained that this was a reasonable approach in a difficult situation.

32. The notes also state that the plan was to perform another scope/cystoscopy in six weeks’ time. Our adviser confirms the scheduled check procedure would then enable any remaining valve leaflets causing an obstruction to be cut and removed.

33. Our adviser also told us that, as urethral dilation is a normal part of the ablation procedure, separate consent would not be necessary, and the operating note documents the procedure that took place.

34. For these reasons, we consider the Trust’s approach was in line with the above guidance and we have seen no indication that the Trust performed an incorrect procedure or that it failed to gain appropriate consent.

35. Mr Q also says the Trust did not involve specialists from the renal team in a timely manner. He says this should have happened due to the severity of his son’s condition. He says this could have a long-term impact on his son as early specialist involvement is essential.

36. During M’s admission he was under the Trust’s neonatal and surgical team. As outlined above, the aim of the procedure M had whilst at the Trust was to improve urine flow, clear the obstruction, and to protect kidney function and bladder development. Our adviser said that, as the experts in neonatal care, they were best placed to manage M’s acute renal issues during his inpatient stay.

37. GMC ‘Good Medical Practice’ guidance says you must refer a patient to another suitably qualified practitioner when this serves their needs.

38. The records indicate that the Trust made a referral to a specialist renal team for M’s long-term follow-up care and management of his condition post-discharge and this was communicated to the family.

39. Our adviser explained that treatment of M’s valves was never a fix for his bladder dysfunction or to resolve his renal issues and that long-term care was always going to be needed.

40. The referral was appropriately made, in line with the GMC guidance, to offer this care post-discharge when M was stable enough and did not need to be in hospital.

41. We appreciate the worry and distress Mr Q experienced during this time and his desire to have the very best specialist care and treatment for his son. We hope that it provides him with reassurance to know that an earlier referral was not needed and did not have an impact on his son’s long-term condition.

42. The records show that continued discussions were had with M’s parents following the procedure and also about the Trust’s plan to revisit the valve destruction. Additionally, the records show that the longer-term plan of referral to another Trust for ongoing care and treatment post-discharge were also discussed.

43. We understand the difficulties M faced following his birth and how hard this was for Mr Q to witness. We also recognise the distress it caused Mr Q to find out that the procedure he had fully consented to had not happened in a way that he considers had been discussed.

44. The records show the Trust’s attempts to explain the situation and the ongoing plan. However, on 2 June 2025, it appears Mr Q remained unhappy and felt like Trust staff had not listened to him or adequately explained things to him.

45. We understand how frustrated Mr Q felt during this period. We recognise that he felt like he was not being listened to or fully involved in the serious discussions and decisions regarding his son’s care and treatment. We appreciate this meant he lost trust in the staff caring for his son and left him wondering whether the Trust’s care and treatment of M had put him at increased risk or negatively impacted his long-term health.

46. On 6 June, the Trust held a meeting with Mr Q and his wife to discuss their concerns. The record from this meeting shows the Trust provided some further clarity on M’s condition and the ongoing plan. Within the meeting the Trust acknowledged that, as M had involvement from a number of clinicians, Mr Q received information from a number of people which at times did not provide consistency. As a result, the Trust agreed to appoint a lead clinician to give structured updates to ensure consistency and clarity for Mr Q and his wife.

47. During the complaints process, the Trust again apologised that its communication could have been better and acknowledged the distress this caused Mr Q.

48. Our ‘NHS Complaints Standards’ explain that when things go wrong, we expect organisations to apologise and ‘see complaints as an opportunity to develop and improve its services.’

49. We have seen the Trust has apologised that its communication fell below the standard it expected and acknowledged the impact this had on Mr Q. It also took action to ensure Mr Q and his wife received more consistent and clear communication to alleviate any further distress during what was a difficult period of time for the family.

50. We consider these actions to be enough to put things right and in line with Our NHS complaints standards. Therefore, we will not be taking any further action.

Discharge and safeguarding action

51. Mr Q says the Trust should not have discharged his son as his blood levels were not safe. He also said the discharge summary did not include information on the surgery that was performed whilst his son was in hospital. He says this had a potential impact on his son’s follow-up care.

52. Mr Q explained that he had notified the Trust of these concerns but that it was misconstrued and reported in his son’s records that he had been ‘aggressive’ and ‘threatening’. Mr Q says these false accusations were subjective and indicates a bias in its documentation and also meant the Trust inappropriately threatened him with safeguarding action.

53. The Government’s ‘Hospital discharge and community support guidance’ explains that discharge should be based on a clinical decision that a person no longer needs to remain in hospital and that their needs can be safely met in the community with appropriate support. A safe discharge is about overall clinical judgement and support, not about every result being normal, and with a clear and well documented plan for ongoing monitoring and specialist follow-up.

54. On 6 June 2025, the Trust held a meeting to discuss some of the concerns Mr Q had raised. The Trust explained that M’s creatinine levels were elevated above normal range. However, these had significantly decreased and were clinically reassuring. Therefore, M was considered medically stable for discharge from hospital with a carefully considered plan for follow-up care.

55. Our adviser confirmed there was no evidence to suggest M’s blood test results were unsafe and would prevent discharge from hospital and there was a clear plan for additional tests and for longer-term care to be provided by an alternative hospital.

56. The records indicate Mr Q declined to take M home.

57. On 9 June, the records indicate that Mr Q was unhappy with the discharge summary contents. The records suggest amendments were made to the discharge summary, but Mr Q again declined to take M home as he remained unhappy with its contents.

58. The Royal College of Physicians Discharge summaries guidance state these are important medical records that summarise a patient’s hospital admission, for the benefit of both the general practitioner (GP) and the patient. A discharge summary should contain a sufficient level of information to ensure that both patients and other healthcare professionals are aware of the relevant events of a hospital admission.

59. Our adviser confirms the discharge summary accurately records the elements of M’s care and management during his time as an inpatient at the Trust. They explained that information is of limited value to M’s family or GP and that more focussed letters are sent to the relevant specialists. They explained that these documents are used for data coding by the neonatal systems and that the surgical operations and codes are on the hospital notes to transfer information to other professionals and is not used as a communication document to or for the family.

60. The Trust considered M to be medically stable, and he was discharged home on 10 June 2025.

61. We have carefully considered all available evidence, and it appears that the discharge summary was in line with the above guidance, and no further amendments to the discharge summary were required following those made on 9 June.

62. We also consider the Trust appropriately considered M’s health and acted in line with the Government’s ‘Hospital discharge and community support guidance’ to safely discharge M home with a clear follow-up care plan in place.

63. ‘Working Together to Safeguard Children’ is statutory guidance and explains the importance of multi-agency working to share information to help, support, and protect children.

64. The Trust says that when babies are medically ready for discharge, and parents decline to take them home, it has a duty to consider whether there are concerning reasons behind that decision. It explained that it needed to consider whether to involve social care to help assess the rationale for the decision as it wanted to ensure M’s care was managed in his best interests. It apologised for any distress this caused.

65. We understand how important it was for Mr Q to feel reassured that his son was safe to return home and that it would not have a negative impact on his health. We also recognise the further upset and distress it caused him when he perceived the Trust had ‘threatened’ him with safeguarding action.

66. Having taken everything into account, we consider it was important for the Trust to ensure there was no underlying reasons for Mr Q’s decision not to take his son home despite medical assurances that it was safe to do so. Therefore, we consider it was appropriate to discuss the possible involvement of social care at this time, in line with ‘Working Together to Safeguard Children’ is statutory guidance. Although, we recognise the distress and frustration this caused Mr Q and this decision is not intended to minimise that.

67. There is documentation relating to Mr Q’s behaviour and we understand this was also discussed during the meeting on 6 June. The records indicate that some members of Trust staff had reported that Mr Q had been aggressive and at times offensive and discriminatory.

68. As we were not present at the time, we cannot reach a decision, even on balance, about what was said or what happened at this time. Therefore, we cannot say that these were ‘false allegation’, just that they were recorded as Trust staff having felt this way about Mr Q’s behaviour.

69. We recognise that having such comments recorded in his son’s notes has been very upsetting for Mr Q, and we understand why he would want his disagreement with those descriptions to be clearly noted. As we have not reached a decision on this part of Mr Q’s complaint, we cannot take any further action. However, this is something Mr Q could ask the Trust to do so that this is clearly reflected within the records should he wish to do so.

70. We hope it provides Mr Q with reassurance to know that we have not seen anything to indicate that this information within the records had an impact on the care and treatment provided to his son during his inpatient stay.