Doctors took skin graft from inappropriate place and without telling the patient

Organisation we investigated: Queen Victoria Hospitals NHS Foundation Trust

Date investigation closed: 12 July 2019

The complaint 

Complainant G complained about the skin graft operation they had at the Trust. Complainant G complained that the surgeon used skin from the shin as a donor site, when they should have used a less visible area. Complainant G also complained that there were no discussions before the skin graft about the suitability of the shin as a donor site, alternative skin graft donor sites or the long-term effects the skin graft would have.

Complainant G told us that they lost the opportunity to decide where the skin would be harvested from for the graft and that they were left with a visible scar on the shin, which has caused them anxiety and distress. 

What we found 

The Trust did not choose a donor site in line with guidance. It should have taken the skin graft from the upper and outer thigh area, where the skin is relatively thick and easy to harvest, and the scar is easier to conceal. The Trust could have taken skin from the lower leg, but only if it was taken from an area directly next to the wound. The Trust took the skin graft from a different area on the leg. 

The Trust did not tell Complainant G that a skin graft was needed, and no discussion took place about the choice of donor site. Complainant G would have chosen a less visible site from which to take the skin graft and has now been left with a permanent scar.


Complainant G fell and cut their leg. The Trust stitched the wound, but it later became infected. Complainant G had dead skin removed from the wound, but it was not possible to close it. The Trust performed a skin graft to resolve the issue, taking the graft from Complainant G’s shin.  

The Trust’s complaint response said that ideally skin should have been harvested from the thigh area rather than the shin when staff performed the procedure.

Putting it right 

The Trust accepted that Complainant G’s skin graft was performed in an unconventional way and that Complainant G is likely to have a permanent residual scar. It also said that learning from this event has been fed back to the surgical team.

We recommended that the Trust should make a payment of £950 in order to acknowledge the impact these failings had on Complainant G.

The Trust complied with our recommendation.

This case summary is featured in the Ombudsman's Casework Report 2019.