The complainant (C) complained to my office about the care and treatment provided during the period January 2018 to September 2021. In January 2018 C underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, C was seen in an outpatient clinic and informed it would be possible to have a stoma reversal.
C complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. C also complained that COVID-19 could not account for the delays between the Board informing C they were ready for surgery around December 2018 and the start of the pandemic in March 2020. C noted that as a consequence they had developed significant complications: a large hernia. C added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.
The Board apologised that C had experienced delays waiting for their operation. They explained that despite a positive reintroduction of surgery in June 2021, they were required to significantly reduce elective surgical activity as COVID-19 patients again increased. C was said to be at the top of the list for their surgery, however, C would require two consultants to perform a joint procedure. They added that there were limited high dependency beds available, necessary for C's post-operative care, causing further delay. The Board were therefore unable to offer a definitive timescale for C's surgery.
I sought independent advice from a consultant general and colorectal surgeon (the Adviser). The Adviser told me that it was unreasonable for C to have waited eight months between being seen in an outpatient clinic in April 2018 and having a flexible sigmoidoscopy (a non-surgical examination) in December 2018. The Adviser considered that this delay had been due to C having been unnecessarily placed on a 'named person list' requiring a specific consultant to carry out what was a routine investigation. The Adviser also noted that it was a further year before C was placed on the waiting list for surgery and that it appeared that there was no monitoring of C's timeline during this period. Lastly, the Adviser told me that there appeared to have been insufficient priority given to C's treatment post-pandemic. In conclusion, the Adviser said that the delays were unreasonable and noted that as a consequence C required more complex, demanding, and risky surgery.
In light of the evidence I have seen and the advice received, I found that: the Board unreasonably delayed performing a reversal of Hartmann's procedure. As such, I upheld C's complaint. I was also critical of the Board's own investigation of C's complaint. During the course of my investigation, in June 2022, C underwent surgery to reverse the Hartmann's procedure and repair the hernia.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for C:
|
What we found |
What the organisation should do |
What we need to see |
|---|---|---|
|
The length of time C waited for a flexible sigmoidoscopy to be carried out was unreasonable. The use of a 'named person' list led to an unreasonable delay in carrying out a flexible sigmoidoscopy. The length of time C waited to be seen at an outpatient clinic in January 2020 to discuss surgery following a flexible sigmoidoscopy was unreasonable. The length of time C waited for their planned surgery was unreasonable. There was a failure in complaint handling by the Board in relation to C's complaint. |
Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. |
A copy or record of the apology. By: 23 December 2022 |
We are asking the Board to improve the way they do things:
|
What we found |
Outcome needed |
What we need to see |
|---|---|---|
| The length of time C waited for a flexible sigmoidoscopy to be carried out was unreasonable. | Patients awaiting elective surgery, particularly flexible sigmoidoscopy/endoscopy should have treatment carried out as soon as possible and where clinically necessary the patient's care should be prioritised. |
Evidence that the Board have reviewed the systems they have in place for the management and prioritisation of patients awaiting elective surgery, particularly in relation to the endoscopy service to ensure that they are both appropriate and effectively managed. By: 23 February 2023
|
| The use of a 'named person' list led to an unreasonable delay in carrying out a flexible sigmoidoscopy. | Patients requiring flexible sigmoidoscopy/endoscopy should be added to the most appropriate waiting list for this type of treatment. |
Evidence that the Board have carried out a review of the use of a named person's list in relation to the endoscopy service. By: 23 January 2023 Evidence of any actions or changes taken or planned as a result, with timescales if part of an ongoing action plan. By: 23 February 2023 |
| The length of time C waited to be seen at an outpatient clinic in January 2020 to discuss surgery following a flexible sigmoidoscopy was unreasonable. | Patients should be followed up at outpatient clinic appointments following flexible sigmoidoscopy/endoscopy within a reasonable timeframe. |
Evidence that the Board have reviewed their arrangements for administering and monitoring the waiting list for outpatient clinic appointments in particular in relation to the endoscopy service, to ensure future delays such as this are avoided with a note of any actions or changes as a result. By: 23 February 2023 |
| The length of time C waited for their planned surgery was unreasonable. | A clear treatment path should be in place for patients whose surgery is delayed that is based on current recognised prioritisation criteria. |
Evidence that my findings have been shared with relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one to-one sessions). By: 23 January 2023 |
We are asking the Board to improve their complaints handling:
|
What we found |
Outcome needed |
What we need to see |
|---|---|---|
|
The Board's own complaint investigation was of poor quality and did not address all of the issues raised by C in their complaint to them. The Board failed to address and acknowledge the significant and unreasonable delays in C's care and treatment, which occurred during the period before the COVID-19 pandemic started. |
The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement. The Board should comply with their complaint handling guidance when investigating and responding to complaints. |
Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one to-one sessions). By: 23 January 2023
|