Decision on the PHSO website ↗ All PHSO decisions
The complaint, background, findings, decision and recommendations on this page are the PHSO's published words. First-person wording refers to the Ombudsman.
1. We have carefully considered Mrs E’s complaint about University Hospital North Midlands NHS Foundation Trust (the Trust).
2. We recognise that it will have been distressing for Mrs E to feel that the health issues she was experiencing were as a result of the surgeon performing the wrong surgery. We acknowledge that she has been significantly impacted by the side effects that she experienced following her initial surgery.
3. After consideration, we have seen evidence that the correct end colostomy surgery was performed on Mrs E in 2017. We will therefore not be considering this complaint further.
From: PHSO decision P-006077, 27 August 2026, on the PHSO website ↗
4. Mrs E complains about the care provided to her at University Hospitals of North Midlands NHS Trust (the Trust).
5. Mrs E says that in 2017 the Trust performed a loop colostomy procedure rather than the end colostomy procedure that she was told she would be getting.
6. Mrs E says that as a result of this:
• she experienced severe pain in the seven years until she had her revision surgery in 2024 • her stoma bag did not work properly, were removing themselves, and her stomach was folding inwards at the site of the stoma. Her stoma bag was also consistently leaking, meaning that she struggled to sleep, or to be able to leave her home • her bowels were uncontrollably leaking from her rectum, this also impacted on her ability to sleep or leave her home • her mental health was significantly impacted due to the symptoms she was experiencing • she has lost faith in the NHS.
7. Mrs E would like the following to remedy her complaint:
• an acknowledgment that it performed the wrong type of surgery in 2017 and an understanding of the impact that this had on her • a financial remedy.
8. Mrs E suffered a bowel prolapse (where the rectum slips out of the normal position and protrudes through the anus) which damaged her vagus nerve and in turned caused her to experience gastroparesis (where food passes through the stomach slower than it should) and dysmotility of her large and small intestines (where the digestive tract does not work as it should, meaning that the rate at which food passes through the digestive system and the rate at which waste is excreted is abnormally slow or irregular) in 2007.
9. Mrs E had multiple surgeries to attempt to fix the bowel prolapse, however in 2015 it was deemed that the operations had sadly been unsuccessful, and that Mrs E needed to undergo an end colostomy procedure. An end colostomy is where the end of the colon is brought through the abdominal wall to create a stoma. A stoma bag will then be used by the patient to allow waste to exit their body.
10. In 2017 Mrs E was admitted to the Trust to have an end colostomy procedure.
11. Following the surgery Mrs E’s stoma bags were ‘rejecting’ from her body and the stoma nurses who were supporting her were struggling to keep them secure despite trying different types of bags.
12. Mrs E explained that between 2018 and 2024 she was experiencing multiple distressing and painful problems with her bowels and stoma bag, that were having a significant impact on her ability to live her life.
13. In 2021 Mrs E had a colonoscopy, a blood transfusion, and a CT scan to investigate her symptoms.
14. In 2023, around 18 months following her colonoscopy, Mrs E returned for her second procedure where the colostomy scope was placed through her stoma. It was at this appointment that the doctor mentioned that the scope was going through her ‘loop colostomy’.
15. On 14 September 2023 Mrs E had a follow up appointment at the Trust to discuss her ongoing symptoms. The Trust reiterated that she had had an end coloscopy done, however agreed to send her for a further scan, where she would have dye sent through her bowel to look for any issues. They said that this would confirm that she had an end coloscopy however if it did not, she would have surgery to convert the loop coloscopy to an end coloscopy.
16. Two weeks following this appointment Mrs E had her scan and she said that it was confirmed that she had had a loop coloscopy done. Mrs E returned to the consultant that she had the follow up appointment with, and she says he expressed his disappointment that Mrs E had had the loop coloscopy done rather than the planned end coloscopy. She says he explained to her that she now needed to have further surgery to convert it to an end coloscopy.
17. On 10 May 2024 Mrs E had her surgery. Following the surgery and her complaint the Trust told her that she had always had an end colostomy, and that the purpose of her surgery was to reattach stitching that had become undone. Mrs E explained that her symptoms have significantly improved since this surgery.
21. Mrs E explained that the Trust performed the wrong surgery on her when she was operated on in 2017. Mrs E said that the Trust performed a loop colostomy rather than the end colostomy that she was referred to it for. Mrs E feels that this caused her multiple distressing side effects until she had her second surgery in 2024.
22. 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.
23. Mr E’s medical records note that on 28 June 2017 she underwent a laparoscopic end colostomy procedure for functional bowel disease.
24. The records explain that on 28 June 2021 Mrs E had a CT scan to investigate some of the symptoms that she was experiencing.
25. We discussed the imaging from this 28 June 2021 scan with our adviser, who helped us to understand what the imaging showed. Our adviser explained that the imaging seemed to show a loop colostomy, however, they told us that the imaging was quite unclear.
26. Mrs E’s records show that she continued to experience negative symptoms relating to her stoma throughout 2021 to 2023. On 3 October 2023, Mrs [name redacted] then had a contrast enema to investigate her symptoms further.
27. A contrast enema is a type of X-ray in which the colon is filled with a contrasting liquid through a tube that is inserted into the patient’s rectum. A contrast enema is done to allow a clear view of a patient’s large intestine and the way that liquid is passing through it.
28. We discussed the imaging of the 3 October 2023 contrast enema with our adviser. They explained that this scan clearly shows an end colostomy.
29. Our adviser explained that a contrast enema is much clearer than a CT scan and that it would be impossible for a loop colostomy to convert itself into an end colostomy without any surgical intervention. Mrs E did not have any further surgeries between her original 2017 surgery, her 2021 CT scan, and her 2024 surgery.
30. The medical records then show that when Mrs E had her further surgery on 10 May 2024, it was confirmed that she had an existing end colostomy. The notes explain that an existing end colostomy was present, but the staples that had been put in in the previous surgery had come away. The surgery note explains that these staples were replaced.
31. Good Medical Practice explains that practitioners must provide a good standard of practice and care, and provide effective treatment based on the best available evidence.
32. In 2021, although the imaging was unclear, it indicated that Mrs E had a loop colostomy. In line with the evidence available to them at the time, Mrs E was advised that she had a loop colostomy.
33. Following this, in 2023, Mrs E’s contrast enema showed that she had an end colostomy. After her 10 May 2024 surgery it was confirmed that she had always had an end colostomy, and that she was experiencing the symptoms that she was because the staples from her surgery had come loose over time.
34. In line with Good Medical Practice, the Trust provided treatment to Mrs E based on the evidence that it had from both the 2023 and 2024 scans, and what it discovered when it was undertaking her surgery.
35. Taking into consideration all the evidence in this case, we consider that the Trust performed the end colostomy surgery in 2017. We will therefore not consider this complaint further, as we have seen no indication of any failings.
36. We recognise that it will have been distressing for Mrs E to be told that her scans showed a loop colostomy. We can see why this has caused her to feel that she has reason to complain. We also recognise that it will have been confusing for Mrs E to then be told that she always had an end colostomy.
37. We appreciate how distressing the symptoms were that Mrs E experienced before her 2024 surgery. We would like to thank her for taking the time to bring her complaint to us.