Ombudsman reports - Healthcare complaint

This is an extract of complaints resolved by the Ombudsman Office in 2025. The Chronicle publishes a report fortnightly.

REPORT ON CASE NO. 1290 

Complaint 

The complaint concerned the Gibraltar Health Authority (“GHA”) and the delay in arranging the removal of the Complainant’s 13-year-old daughter’s temporary ureteric stent. The Complainant was concerned that the stent had remained in place for approximately six months, during which time the Patient experienced significant pain, bleeding and discomfort. The Complainant believed that the delay had contributed to the stent becoming encrusted and ultimately resulted in the Patient requiring more extensive surgery than originally anticipated. (ombudsman.org.gi⁠) 

Background 

The Patient attended A&E on 14 July 2023 after experiencing extreme pain and vomiting. An obstruction involving the left pelvic-ureteric junction (“PUJ”) was identified. She was referred to GHA urologists and a temporary urinary stent was inserted on 16 July 2023. 

The intention was for the Patient to receive definitive treatment in the United Kingdom. However, following insertion of the stent, she continued to experience pain and discomfort. Her symptoms became sufficiently severe that she was admitted to the children’s ward in November 2023. 

The Complainant repeatedly contacted the Sponsored Patients Department in an effort to expedite the Patient’s treatment. Ultimately, the Patient was not treated by the UK specialists until approximately six months after the stent had been inserted. 

The Complainant was particularly concerned that the prolonged period with the stent had caused significant encrustation. The definitive operation, originally expected to be performed using keyhole surgery, became more complicated and required open surgery, leaving the Patient with a substantial abdominal scar. 

The Complainant also raised concerns that her daughter had experienced pain and other symptoms from an early age and questioned whether the GHA should have identified the underlying obstruction earlier.  

Investigation 

The Ombudsman reviewed the GHA’s internal complaints file and the Patient’s medical records. Because the complaint involved clinical matters, the Ombudsman sought independent specialist medical advice from a UK Consultant Urologist with more than 30 years’ experience in renal and upper urinary tract conditions. 

The Expert explained that time was a significant factor in the risk of ureteric stent encrustation. Although the particular stent had a manufacturer-referenced maximum indwelling period of six to twelve months, the clinical risk of encrustation increased substantially much earlier. The Expert considered that symptomatic stents should be reassessed promptly. 

The Expert concluded that the prolonged period during which the stent remained in place increased the likelihood of significant encrustation. He considered that this was probably responsible for the difficulties encountered during the Patient’s attempted laparoscopic surgery, resulting in the need for open surgery. 

The Expert also considered what happened when the Patient attended A&E again in November 2023 with significant pain. He considered that targeted imaging at that point might have identified encrustation and could potentially have resulted in earlier stent replacement or intervention. 

The Expert also identified that a DMSA scan recommended by the UK specialist had not been carried out as requested. Instead, a different test was performed. The Expert explained that the recommended test was intended to assess kidney function before definitive surgery and that the alternative test did not provide the same assessment of renal drainage. 

The Expert did not, however, consider that the Patient’s earlier childhood investigations demonstrated a failure by the GHA. The ultrasounds undertaken in 2011 and 2016 had been assessed according to the relevant local guidelines, and there was insufficient evidence that earlier follow-up would have substantially changed the Patient’s prognosis.  

Conclusions 

The Ombudsman accepted that the initial insertion of the stent had been appropriate. The central concern was what happened afterwards. 

The independent Expert considered that there had been insufficient interim management of the symptomatic stent. In particular, the Patient should have received prompt reassessment and appropriate imaging when she continued to experience symptoms. 

The GHA disagreed with some aspects of the Expert’s conclusions. Its urologists explained that they had maintained regular communication with the family and had assessed the Patient whenever she presented with symptoms. They also argued that imaging in November 2023 had not been clinically necessary because inflammatory markers were normal and urine cultures were negative. 

The GHA further explained that Gibraltar’s healthcare system depended on external UK providers for specialist paediatric treatment and nuclear medicine investigations. Waiting times and the availability of UK services therefore contributed to the overall delay. 

The Ombudsman nevertheless endorsed the Expert’s findings. She concluded that the absence of appropriate interim stent management increased the risk of encrustation and contributed to the need to convert what had been intended as laparoscopic surgery into open surgery. 

The Ombudsman also recognised that responsibility for the overall delay did not rest entirely with the GHA. The Patient’s definitive treatment depended partly upon the UK healthcare system. Nevertheless, the GHA had a responsibility to manage the Patient appropriately while she remained under its care. 

The Ombudsman was particularly concerned about the impact on the Patient, who was only thirteen years old. She had endured prolonged pain and distress, with consequences for her education and ordinary daily life. The Ombudsman considered that some of this distress could potentially have been avoided through better interim management of the stent. (ombudsman.org.gi⁠) 

Classification 

Sustained 

The complaint that the GHA had taken too long to arrange the removal of the Patient’s temporary ureteric stent was sustained. 

The Ombudsman did not find that the original diagnosis or insertion of the stent had been inappropriate, nor did she find sufficient evidence that the earlier childhood investigations had been deficient. 

Recommendations 

The Ombudsman recommended that the GHA: 

1. Offer the Patient a sincere apology for the shortcomings identified in her care; and
2. Improve the written information provided to patients and carers when a stent is inserted, including information about expected symptoms, warning signs, points of contact and anticipated timelines for review.

The case highlights the importance of effective follow-up care, particularly where temporary medical devices remain in place for extended periods. It also demonstrates the Ombudsman’s role in obtaining independent clinical expertise where a complaint cannot fairly be assessed through administrative evidence alone.