In the realm of healthcare, trust is a cornerstone of the patient-provider relationship. Yet, for one patient, this trust was severely undermined by a series of events that not only impacted their health but also altered the trajectory of their life. This is their story, anonymised for privacy, and a call to action for systemic reform.

A Procedure Gone Wrong

In 2016, the patient underwent a medical procedure involving a Hickman line at a major hospital in the United Kingdom. While the procedure itself went well, complications arose during the follow-up care. The Hickman line, which was intended to be cleaned and maintained by a local GP practice, was never attended to by the GP staff despite an appointment being made. Two weeks later, the line was flushed during its removal in the hospital’s outpatient department, contrary to the guidance provided before the procedure.

The patient recalls explicitly warning the nurse against flushing the line, as advised during a pre-procedure meeting. However, the nurse dismissed their concerns, stating it would be fine. Shortly after, the patient developed sepsis, a life-threatening condition. They struggled to return to the outpatient department, requiring the support of other patients after becoming weak, cold, and shaky. Upon arrival, a consultant immediately recognised the severity of their condition, declaring, “Nurse, Nurse, get this man a bed, he has sepsis.”

A Cascade of Failures

While the hospital focused on managing the sepsis, they overlooked another significant risk highlighted during pre-procedure counselling: Epstein-Barr Virus (EBV). Despite assurances that EBV would be closely monitored, the condition was not recognised for months. When eventually tested, the results were sent abroad and subsequently lost, leading to further delays in diagnosis and treatment.

During this time, the patient received incorrect medication despite repeated instructions from a senior consultant to change it. The lead professor of the Haematology department at King’s College Hospital, Professor Mufti, identified that the patient was being given the wrong drugs but was ignored. This prolonged exposure to the wrong drugs compounded their health challenges. Additionally, the patient’s stay in the hospital was marked by inadequate physiotherapy, leaving them bedbound in a side room for months.

Eventually, the patient was transferred to another facility to aid their mobility recovery. Although they resisted being fitted for a wheelchair, they have relied on crutches ever since.

Delayed GP Appointment

A final GP appointment, intended to arrange follow-up care, was never actually made. The patient attempted multiple times to finalise this appointment, only to be told that a doctor would call back to arrange it. Despite chasing up these calls, no callback was ever received. Already in a weak mental and physical state after their prolonged hospital stay, the patient found themselves unable to summon the energy to try again.

Mishandled Information and Lost Records

The patient’s efforts to hold the hospital accountable revealed further systemic issues. They sought information from King’s College Hospital and were met with a delayed and inadequate response. Executive Medical Director Professor Julia Wendon, writing on behalf of Chief Executive Nick Moberly, issued a response that appeared to purposefully misunderstand the patient’s request and provided little detail.

After paying for copies of their medical records to pursue legal action, the patient discovered that one critical piece of information was missing. Their solicitor, Janine Collier from Tees Law, confirmed this discrepancy, raising concerns as only the patient and their solicitor had handled the paperwork. When the patient contacted the hospital’s Patient Advice and Liaison Service (PALS) to report the missing document, they were told, “We don’t know where it is, but feel free to come and look for it yourself if you want.”

Navigating Advocacy Services

Seeking support, the patient turned to advocacy services, initially engaging with Voiceability in September 2027 (Ref: DH17399). However, the case was passed between advocates—first from Louise Clarke to Gillian Marsh—without the patient’s knowledge. They only discovered this change after chasing up their case weeks later, forcing them to explain their situation anew.

Voiceability eventually closed down mid-claim without notifying the patient, leaving them adrift. Subsequently, the patient was contacted by Advocacy for All, where Giles Frampton took over their case. Frampton’s diligent efforts brought much-needed stability, ultimately enabling the patient to move forward. With Frampton’s detailed summary and support from Labour MP Sarah Jones, the case was presented to the Ombudsman.

The Struggle for Accountability

While at King’s College Hospital, the patient was given three weeks of private healthcare in the Guthrie Ward—a gesture they believe was an attempt to mute their complaints. The patient’s pursuit of justice faced countless hurdles. Despite their determination, systemic delays and procedural barriers hindered progress at every turn. Correspondence from Baroness Merron highlighted the limitations of existing complaint mechanisms and the challenges of seeking recourse through judicial review. Letters from supportive MPs further emphasised the profound and irreversible impact of the hospital’s failings on the patient’s life.

A Life Altered

Before these events, the patient led an independent and fulfilling life, working full-time in a demanding role. Today, they rely on mobility aids and can only work part-time, with significantly diminished career opportunities and income. The physical and emotional toll of their experience continues to shape their daily life.

A Call for Change

This case highlights critical systemic issues in the healthcare and complaints process:

1. Accountability in Follow-Up Care: Clear protocols must be enforced to prevent errors during post-procedure care, particularly when high-risk procedures like flushing Hickman lines are involved.
2. Advocacy Delays: Patients must have access to timely and consistent support when navigating complex complaints systems.
3. Transparency in Record Keeping: Missing medical records undermine trust and prevent patients from seeking redress. A robust system for maintaining and accessing records is essential.
4. Time Limit Extensions: The 12-month time limit for escalating complaints to the Parliamentary and Health Service Ombudsman (PHSO) should allow greater flexibility in exceptional circumstances, particularly when health and systemic delays are factors.
5. Transparent Investigations: The PHSO must ensure that objections from healthcare providers do not unduly influence decisions to investigate complaints.

Moving Forward

This patient’s courage in sharing their story underscores the urgent need for systemic reform. Advocacy groups, policymakers, and healthcare professionals must work together to create a more equitable and transparent system. Every patient deserves the assurance that their concerns will be heard and addressed with fairness and urgency.

If you or someone you know has faced similar challenges, consider reaching out to advocacy organisations or patient safety groups. Together, we can push for meaningful change to protect future patients from enduring such ordeals.

This story is shared with the permission of the individual involved, whose identity has been anonymised to respect their privacy. Their resilience and determination serve as a powerful reminder of the importance of accountability in healthcare.

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