What Mr A says
13. Mr A recalls the Trust cancelled his operation on 18 December 2019 due to a lack of beds. Mr A says the Trust told him this over the phone and he remembers he got upset about it as he was wondering when his operation was likely to be. He recalls this first cancellation did not come with a rescheduled date.
14. Mr A says he was not aware the Trust brought his operation forward to 4 December 2019. He says he did not complain to the Trust, or initially to us, about the cancellation of the 4 December operation as he did not know about it until our primary investigation.
15. He says he spoke to his wife about how close the 18 December operation was to Christmas. As he has young children and had waited so long, he decided he would go ahead with the operation, have Christmas at home in a ‘comfy chair’ and rearrange plans.
16. Mr A explained he therefore would have been very happy with an earlier date of 4 December as it would have meant more time for him to recover before Christmas. He told us he did not and would not have cancelled the 4 December 2019 operation if the Trust had offered him this.
17. Mr A says the consultant told him having an up-to-date MRI scan would be ‘nice but not necessary’. He feels it was unreasonable for the Trust to have cancelled his operation booked for 8 January 2020 due to not having an up-to-date MRI scan.
18. Mr A was unable to locate any relevant appointment/cancellation letters.
What the Trust says
19. The Trust did not comment on the 18 December and 4 December 2019 operation cancellations and the reasons for them in its complaint response.
20. The Trust said in its comments to us it cancelled the 18 December 2019 operation on 14 November 2019 to bring Mr A’s operation forward to 4 December 2019. It said this was due to patient cancellations.
21. When we asked for more information, the Trust sent us two sets of systems records it had. One system record says, ‘operation date forward/put back’. A second system record also says ‘patient brought forward/put back’ to 4 December 2019. It also explained the whole elective surgical list was cancelled on 18 December 2019 due to lack of ward beds.
22. The Trust told us Mr A cancelled the 4 December 2019 operation as he wanted his operation in January 2020. The Trust’s system record states ‘patient request’ as cancellation reason and the other says ‘at patient request to cancel and rebook’.
23. The Trust also said in its comments to us there is no information available to confirm it informed Mr A of the 4 December 2019 operation date.
24. The Trust could not provide an appointment letter to show it informed Mr A about the operation on 4 December 2019. The Trust sent us a screenshot of a list of letters its IT team could not print due to Mr A now being discharged.
25. This list included a letter which could be related to the 4 December 2019 operation as it stated ‘request date 14/11/2019’ and ‘D FLOOR ADMIT POSTPONE/NEW’. It is not clear whether this letter was related to this operation, and we do not know its contents or whether it sent any letter about this operation to Mr A.
26. The Trust explained in its complaint response and initial comments to us that it cancelled Mr A’s operation scheduled for 8 January 2020 as he did not have an up-to-date MRI scan. The Trust further clarified to us after speaking to the consultant orthopaedic surgeon that it needed an MRI scan for clinical purposes due to it being 12 months since the previous scan (2018). This was to identify any changes in the intervening period.
27. The Trust said the consultant surgeon confirmed there are no written guidelines saying there has to be a recent scan, but it is commonly mentioned in medicolegal seminars and presentations given at conferences such as the British Associations of Spinal Surgeons and North American Spine Society. The consultant surgeon said it was a generally accepted best practice as scans rarely change within a year but may change if more than a year apart.
28. The consultant surgeon’s record entry for 18 November 2019 conflicts with this and states ‘as his last scan is from September 2018, I am going to get an up-to-date MRI pre-op, but this should not preclude us going ahead if the scan has not been performed in time’.
29. We asked the Trust to explain an apparent discrepancy. We explained it appears it would have been happy to go ahead with the operation on 4 or 18 December 2019 without an up-to-date MRI scan, but not the 8 January 2020 operation.
30. The Trust told us it only operated on two patients on 8 January 2020 and the prioritisation of patients was likely to have included the consideration there was no up-to-date MRI scan available.
31. When we confirmed the investigation, the Trust gave us the consultant surgeon’s comments. The consultant surgeon said his recollection is the Trust cancelled the operation because there was a lack of available beds, not because the Trust needed to get an up-to-date MRI scan. It said lack of beds was the primary reason and delaying Mr A’s operation had a secondary benefit of making sure he had an up-to-date MRI scan by his next scheduled operation.
32. The system records of cancellations state the reason for cancellation of the 8 January 2020 operation was ‘consultant decision’ and ‘needs updated MRI’.
33. The Trust told us it has no documented policy on cancelling operations. It explained its process is that it makes such decisions through a structured decision-making process with clinical and operational staff, with consideration of a range of factors including clinical priority, length of time waited, complexity of operation, theatre requirements and availability, specialist equipment, specialist staff and availability of beds.
34. Weighing up the evidence we have seen, there is good evidence to show the Trust did cancel the operation on 18 December 2019 to bring the operation forward.
35. On the evidence we have seen, the Trust has not been able to show it informed Mr A that it had moved his operation forward to 4 December 2019. Mr A also gives a compelling account about how he was not aware of this operation date and how he did not cancel this operation and why he would not have. Our view is that the Trust did not inform Mr A about the 4 December 2019 operation and that the Trust cancelled this operation. On the balance of probabilities, the cancellation was a mistake, and we cannot see why it made this mistake.
36. The Trust provided us with three different accounts about the reason for the cancellation of the operation on 8 January 2020. It initially said it was due to the lack of up-to-date MRI scan. It then said it was due to lack of beds and it likely did not prioritise Mr A because of the lack of MRI scan. It then said the primary reason was a lack of beds and not the lack of MRI scan.
37. The records also show discrepancies. They show a lack of MRI scan should not stop the operation from going ahead, but the reasons for the cancellation noted in the records are ‘consultant decision’ and ‘needs updated MRI’. The evidence we have seen shows the Trust would have been happy to go ahead on the previous operation dates (4 and 18 December 2019) without an up-to-date MRI scan.
38. Having weighed up all available evidence, we can say on the balance of probabilities that the lack of MRI scan was a factor, although not the only factor, in the Trust cancelling Mr A’s operation on 8 January 2020. We cannot know the extent to which the MRI was a factor due to the conflicting accounts and unclear information we have. We have seen the Trust did not properly and consistently document its rationale for cancelling this operation.
39. Paragraph 32 of the GMC’s ‘Good medical practice’ states ‘You must give patients the information they want or need to know in a way they can understand. [..]’. In line with the GMC’s guidance, we would expect the Trust to inform Mr A of his scheduled operations, cancellations and the reasons for any cancellations.
40. The Trust did not clearly explain to Mr A the reasons for the three cancellations we have investigated. The Trust also failed to inform Mr A when it brought his operation forward to 4 December 2019. Our view is that the Trust failed to communicate properly to Mr A and did not give him the information he needed to know.
41. Our ‘Principles of good administration’ say an organisation should make sure its decisions and actions are proportionate, appropriate and fair. The Trust’s mistake in cancelling Mr A’s operation on 4 December 2019 was not appropriate or fair. The Trust’s changing and conflicting accounts indicate it is unsure why it cancelled his operation on 8 January 2020 and it is unsure to what extent it considered the lack of MRI scan as a factor in its decision.
42. We have seen evidence the consultant surgeon told Mr A the lack of up-to-date MRI scan should not prevent the operation from going ahead. We have also seen the Trust was willing to operate on Mr A on two earlier occasions without an up-to-date MRI scan.
43. On the evidence we have seen we cannot say the Trust’s decisions were robust and that it acted fairly, appropriately and proportionately and considered all these factors when it cancelled Mr A’s operations scheduled for 4 December 2019 and 8 January 2020. Our view is that the Trust failed to act fairly, appropriately and proportionately. We have found failings in how the Trust managed and communicated the operation cancellations.
Findings on impact
Mr A’s account
44. Mr A says because of the Trust’s failings, it delayed his treatment (the operation). He says this prolonged the constant physical pain he was in. He says he could not drive before his operation, and he was on ten tramadol tablets every day. He says he went from being an athletic firefighter to not being able to lift his children out of the bath.
45. Mr A also says this also contributed to a deterioration of his mental health. He says his family suffered because his restricted mobility meant he was unable to do activities with them or book holidays. He also had to take time off from his work as a firefighter.
46. Mr A told us over the period 2016 to 2020 he had to take around ten weeks off work and lost around £4,000. He said he had to take time off for injections which was the treatment before the operation. He said he had the ‘odd day/week off’ during the period the Trust cancelled his operations because of the pain he was in.
47. Mr A said in his occupation he gets a retaining fee per month and an additional pay for each callout he attends. When his employer put him on light duties and then sick leave his pay went down, in part due to no callout fees. By the time he had his operation he was on statutory sick pay, so was financially affected. He said he had to take 12 weeks off after the operation.
Our findings
48. Mr A had his surgery on 9 March 2020. We have seen that if the Trust had not cancelled the 4 December 2019 operation, Mr A would have had his operation over 13 weeks sooner. We can see there is a direct link between the 13-week delay and Mr A’s prolonged pain and distress because of this pain.
49. Mr A’s condition caused the pain he was experiencing but we have found the Trust could have alleviated his pain 13 weeks sooner. This is because Mr A told us that the operation relieved his pain. It would also have meant the Trust would have done the operation within the 18-week referral to treatment waiting time set out in NHS England’s 'Guide to NHS waiting times in England'. It missed this because it wrongly cancelled the 4 December 2019 operation.
50. We cannot say with any certainty that Mr A would have had the operation on 8 January 2020, even if the Trust had disregarded the lack of recent MRI scan. This is because the lack of beds may have been a factor in the decision. In any case the Trust’s cancellation of this operation did not add any further impact to the 13-week delay caused by the cancellation of the 4 December 2019 operation.
51. We have considered the financial impact Mr A told us about. This impact spans much wider than the period of failings we are looking at. We can see Mr A was financially impacted before the cancelled operations because he needed time off work due to the pain and time off after injections. We appreciate this was a very difficult time for Mr A.
52. Our investigation is focused on the period 4 December 2019 to 9 March 2020. The impact here which is linked to the failings we have found is that the prolonged pain he experienced meant he took the ‘odd day/week off work’. The reduction to statutory sick pay did not result solely from taking time off whilst waiting for the operations. This was because of time taken off for a wider period whilst trialling different treatment options. We cannot say that the time taken to recover from the operation was linked to the cancellations, as Mr A would have always had to take time off work to recover from his operation.
What the Trust has done to put things right
53. The Trust has not acknowledged to Mr A any failings or provided any apologies in relation to the three operation cancellations we are looking at. It did not comment on the impact of these cancellations on Mr A. It apologised for the consultant not having made it clear an MRI scan was needed for the operation to go ahead.