The Trust
Staff failed to communicate with the Hospital to provide Mrs E with MRSA decolonisation
17. NICE guidance on surgical site infections recommends MRSA decolonisation only in cases where there is an increased risk of surgical site infection. It says recommendations are to be determined locally (specific to each hospital) as it is important to consider the type of procedure, individual patient risk factors and the impact of infection should it occur. They did not specify timings for decolonisation as the research is limited but explain nasal decolonisation can be done from two days prior to surgery to three days after surgery.
18. Our adviser explained this guidance is not to be used as a stand-alone guide but is to be used with local arrangements as local anti-infection practices and the type of infections seen can differ from hospital to hospital.
19. Mrs E says staff from the Trust failed to communicate with the Hospital to provide her with MRSA decolonisation prior to her surgery. She says that should she not have had this, then she would not have been able to comply with any pre-surgery protocols for MRSA prevention
20. In its response, the Trust says there was a communication breakdown between it’s pre-assessment department and the Hospital’s which led to Mrs E not receiving her MRSA decolonisation in a timely manner. It also explained this matter has been corrected between both departments and apologised for the situation Mrs E experienced.
21. Our adviser says Mrs E’s surgery had an increased risk of infection as it involves an implanted medical device, and the impact of infection is considerable as it would necessitate removal of the whole system. If the device was important in her pain management, there would be a period where it would be unavailable until staff inserted a new device later.
22. MRSA decolonisation was recommended locally for a procedure that has an increased risk of infection that may have a significant impact. Therefore, in line with guidance, we consider the Trust should have advised the Hospital to provide MRSA decolonisation as this would have been important in reducing the risk of surgical site infection. We consider this to be a failing.
Impact
23. Next, we will consider the impact of this failing. Mrs E says she has been caused a lot of worry, distress, upset and disappointment.
24. Although this had no clinical impact to Mrs E as she received her MRSA decolonisation before her planned surgery, we understand the worry it would have caused. Also, we consider had staff communicated this with the Hospital, then it may have meant a less stressful time for Mrs E before her planned surgery.
Staff should have contacted Mrs E to advise her to stop taking her Clopidogrel medication
25. Guidance on interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications says there should be a duration of seven days before any surgery if a decision has been made for a patient to stop their Clopidogrel medication.
26. Mrs E says staff should have contacted her to advise her to stop taking Clopidogrel, an anti-coagulant medication, before her surgery; she had to contact the Trust to enquire about it.
27. In its response, the Trust says it spoke to the consultant about the failure to communicate with Mrs E about stopping Clopidogrel. It says there is a telephone record on 8 July 2020 (twelve days before the surgery) where the consultant advised not to stop taking it as it was not necessary for battery replacement surgery. The Trust also confirmed the surgery would not have been cancelled due to not stopping this medication.
28. Our adviser explained surgery to replace a SCS battery is considered low risk for serious bleeding complications and any bleeding is minor and easily dealt with intraoperatively. An operating surgeon makes the decision to stop Clopidogrel medication based on a risk assessment of bleeding versus cardiovascular risk.
29. Mrs E’s surgery was booked for 20 July, and had she been required to stop Clopidrogel, in line with the guidance we have explained, she should have been advised to stop this within seven days of her surgery.
30. We understand Mrs E’s concerns that she may have had to stop Clopidrogrel, and this was why she contacted the Trust. From Mrs E’s clinical records, we have seen staff recommended during her telephone appointment on 8 July that she should not stop taking this medication and a letter was also issued with this advice to Mrs E and her GP. However, had there been a requirement to stop taking it, staff would not have needed to contact her to advise of this until 13 July at the latest. As such, in line with guidance, we have found no failings with staff not contacting Mrs E to tell her to stop taking her Clopidogrel.
The Hospital
Staff forgot to book a representative for Mrs E’s surgery
31. There are no national recommendations or standards which set out when staff should book a representative for surgery. However, in line with the Ombudsman’s clinical standards our adviser has given their professional judgement and reasoning.
32. Our adviser noted that as neuromodulation (technology which acts directly upon nerves) devices are becoming more complicated and as technology progresses, it is common to have a representative of the medical device company to assist in the programming and preparation of the necessary hardware in the operating theatre. Many clinicians who implant these devices and nurses are unfamiliar with the precise programming for each manufacturer and it is usual for the company representatives to perform this task.
33. Mrs E says staff forgot to book a representative to ensure they were present for her surgery which resulted in her not being taken to theatres as the first operation of the day. As she was unsure whether her surgery would then be carried out that day, she decided to leave the Hospital and not have her surgery.
34. In its response, the Hospital unfortunately says the member of staff who was responsible for booking theatre representatives went off sick unexpectantly. This meant Mrs E’s representative had not been booked for her surgery.
35. Our adviser explained the Hospital should have booked a representative as they may be necessary for both the surgery and the programming afterwards of Mrs E’s device. The representative can ensure that specific equipment is available for the surgery, in this case it was crucial that the correct battery was chosen to replace the existing one. During Mrs E’s surgery, the representative could also check the battery is correctly connected to the electrodes. This cannot be done by the operator although an appropriately trained nurse can perform this role.
36. The representative may also check the new battery programs and re-program if necessary. Our adviser says this is not done by the operating surgeon as it can be time consuming and will delay the continuation of the operating list. However, it can also be done by an appropriately trained nurse if available.
37. Therefore, in line with our adviser’s professional judgement and reasoning, we consider staff not booking a representative for Mrs E’s planned surgery was a failing.
Impact
38. Mrs E says this has caused her and her family a lot of worry, distress, upset and disappointment. Her husband had to isolate with her for two weeks before her planned surgery and had to take unpaid leave from his work which affected their household income by £350.
39. There were three surgeries booked for 20 July and due to this error, Mrs E says only two of the surgeries would be carried out that day. Mrs E decided to go home and not have her surgery that day. We understand her reason for this was that she felt everything was indicating her surgery would not go ahead that day.
40. We recognise that, for a multitude of reasons, surgeries can be cancelled on the day they are planned. From the Hospital’s response, it is our understanding the representative did arrive later that morning and was available for the procedure. Therefore, though the representative was not booked in advance, the Hospital recovered its position, and a representative was present later in the day. From reviewing the Hospital’s response and Mrs E’s medical records, we have not seen anything documented to say the surgery would have been cancelled.
41. As such, we cannot say with confidence that Mrs E’s surgery would not have gone ahead. By choosing to discharge herself and go home, Mrs E took a decision to remove herself from the opportunity for surgery, albeit if the surgery did occur, she would not have been first in theatre on that day. Therefore, we are unable to link the injustice that the above failing affected Mrs E and her husband’s household income.
42. However, we recognise that learning the representative had not been booked would have caused her some distress, upset and disappointment as she was expecting to be the first patient for her surgical procedure that morning.
Staff told Mrs E incorrect information that she had to self-isolate for two weeks after her surgery
43. Intercollegiate General Surgery Guidance on COVID-19 applies to general surgery for patients who have isolated for 14 days before their surgery and been tested by a throat swab within 72 hours of surgery. Our adviser also provided their professional judgement and reasoning. From this evidence we understand that self-isolation was required prior to surgery but not afterwards. Self-isolation was not required after surgery unless patients developed COVID-19 during their hospital stay.
44. Mrs E says that when she was getting booked in for her surgery on 20 July, the nurse told her verbally she had to self-isolate for two weeks after it, which was incorrect information.
45. In its response, the Hospital says when Mrs E attended for her surgery, any requirement for self-isolation was led by the consultant. The nurse should not have informed Mrs E that she needed to self-isolate as this was a discussion to be had by the consultant if they thought it was necessary. The consultant also confirmed there was no requirement for Mrs E to self-isolate after her planned surgery.
46. While we have no third-party independent evidence of what was discussed between the nurse and Mrs E, the Hospital has said in its response Mrs E should not have been told she needed to isolate. Therefore, we consider on the balance of probabilities based on the Hospital’s response, Mrs E was likely told that she needed to isolate after her surgery. Our adviser says self-isolation would only have been required if Mrs E developed COVID-19 symptoms during her hospital stay. As such we consider Mrs E being told this incorrect information was a failing.
Impact
47. Mrs E says this has caused her and her family a lot of worry, distress, upset and disappointment. We consider being told this information would have caused Mrs E further additional stress especially at a time when it is likely she would have been somewhat anxious whilst waiting for her surgery to take place.
Staff made Mrs E feel berated and ushered her back to her room when she asked to make a call
48. The Hospital’s Clinical Pathways Launch Red/Amber/Green guidance explains patients should be admitted to a single room and there should be no waiting in any corridors or waiting rooms. The Hospital has explained to us this presentation and guidance was delivered to all its ward staff.
49. Mrs E says she left her room to ask to make a telephone call, however she was ushered back by staff and felt berated.
50. In its response, the Hospital says part of its comprehensive infection prevention processes during the COVID-19 pandemic required patients to remain in their rooms for the safety of everyone including staff. It says this should have been communicated in an informative manner and apologised if this was not the case.
51. In line with the Hospital’s guidance, we have found patients should be admitted to a single room and we consider they should not leave their room. We understand Mrs E needed to make a telephone call and left her room. However, we would expect staff to direct her back to room as there was to be no waiting in other areas of the Hospital.
52. Next, we went on to consider how staff managed this situation. Here we have Mrs E explaining she felt berated by staff when she was ushered back to her room. We do not dispute how Mrs E says this made her feel.
53. Our own policy says we should consider the evidence provided to us by all parties to the complaint including eye-witness accounts. We also considered whether there would be any further evidence such as CCTV footage with audio. However, given that this complaint was raised some time ago and the passage of time that has passed, it is likely there is no impartial evidence available that would help us reach a decision here, nor do we consider pursuing said footage would be proportionate to the injustice level claimed, this being a one-off occurrence of a relatively short duration. We understand this may be frustrating for Mrs E and it is not our intention to dismiss how she felt. But as an organisation not present at the time Mrs E requested to make a telephone call, we are unable to determine exactly how staff verbally handled this situation and reach a view that there was a failing.
54. While we are unable to reach a view as to whether there was a failing here, we are pleased to see the Hospital has apologised.