Internal Reference Number: FOI_9052
Date Request Received: 24/11/2025 00:00:00
Date Request Replied To: 19/12/2025 00:00:00
This response was sent via: By Email
Request Summary: Keloid Management Policies, Training, Governance, Audit & Complaint Handling
Request Category: Private Individuals
| Question Number 1: Clinical Guidelines & Policies Please provide copies of all current and past (since 2023) Trust policies, protocols, or guidance relating to: i) Management of keloid scars within the Plastics or Dermatology departments. ii) Use of intralesional steroid injections (e.g., Triamcinolone) including: * Recommended dosing ranges * Recommended injection frequency * Safety guidelines or monitoring requirements iii) Criteria for escalation for surgical excision for keloid scars. iv) Consent procedures for steroid injections and for minor surgical procedures v) Documentation standards for outpatient procedures, including injection documentation vi) Communication standards for letters sent to GPs following outpatient appointments vii) Policies relating to accurate recording of patient demographic information, including gender marker and NHS number updates. | |
| Answer To Question 1: Daily invasive procedures are performed on patients with their consent using standard consent forms with risks and complications explained and documented, or for the administration of steroid injections in clinic, with verbal consent between the clinician and the patient in clinic. There are no specific hard protocols re dose etc at the hospital and nationally we can see no hard and fast ruling. Again there is no specific rule on who and when surgery should be offered to. This is highly patient and surgeon specific, and surgeons can decline surgery at any time if they feel it is not appropriate and refer on to a colleague if the patient wants. Again we all document interactions and minor procedures (such as injections) in the patients notes and letters are sent to GPs by all doctors. There is no standard format; we give as much information as would be helpful to the GP. | |
| Question Number 2: Training. Competency & Authorisation For clinicians who perform intralesional steroid injections for keloid scars. i) Required training, competency assessments, or certifications ii) Whether a specific competency sign-of is required before performing injections iii) The Trust鈥檚 training policy for safe administration of intralesional steroids iv) Any audit or record of clinician鈥檚 authorisation or competency to perform these injections. | |
| Answer To Question 2: Clinicians don鈥檛 required specialist sign off or extra training to do injections as this is a normal part of their job that clinicians are trained to do. | |
| Question Number 3: Governance & Audit Please provide: i) Any clinical audits involving: * keloid treatment outcomes * steroid injection outcomes * surgical outcomes for keloids ii) Any audit reports or quality improvement projects relating to documentation accuracy or procedure recording in outpatient Plastics. iii) Any incident reports or 鈥榣essons learned鈥� documents relating to misgendering of patients, demographic data errors, or documentation errors (anonymised). | |
| Answer To Question 3: i and ii 鈥� The team are not aware of audits or training logs for this as that is not routine procedure to capture. iii - 40 (28 - demographic data errors, 12 - documentation errors, and 0 -misgendering of patients) | |
| Question Number 4: Complaints Handling Please provide: i) The Trust鈥檚 complaints handling policy and internal investigation timescales (specifically including the 40-working-day standard) ii) The number of complaints received since 2023 relating to: * the Plastics Department * keloid treatment * documentation errors * misgendering or demographic data inaccuracies iii) How many of these complaints were upheld, partially upheld, or not upheld. (Please anonymise all patient or staff details) | |
| Answer To Question 4: i) attached policy ii) The plastics department - 53 complaints/concerns received Keloid treatment - 1 complaint Documentation errors - Cannot answer this without going through every single complaint which would be too time consuming. Misgendering or demographic data inaccuracies - 1 complaint iii) Upheld - 5 Partially upheld - 5 Not upheld - 25 To accompany this answer to question 4 please also see the documents listed below:  Complaints Process - Complaints Policy November 2023 v2.pptx | |
| Question Number 5: Activity & Treatment Data For the Plastics Department only (2023-present). i) Number of patients treated for keloid scars each year ii) Number who received steroid injections vs. surgical excision iii) Average waiting times for: * first Plastics appointment for keloids * surgical excision for keloids iv) The number of patients whose referral specifically requested surgical excision but received steroid injections instead. | |
| Answer To Question 5: Please see our response to this question in the spreadsheet attached. Please note, iv) we do not have this information as referral specific request details are not contained within our data warehouse so are unable to be analysed. To accompany this answer to question 5 please also see the documents listed below:  13385 - FOI_9052 - Keloid Management Policies, Training, Governance, Audit and Complaint Handling.xlsx | |
| Please see Attachments: | |
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Our staff at 91影视 District Hospital have long been well regarded for the quality of care and treatment they provide for our patients and for their innovation, commitment and professionalism. This has been recognised in a wide range of achievements and it is reflected in our award of NHS Foundation Trust status. This is afforded to hospitals that provide the highest standards of care.
