18. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have seen the poor communication from the Trust meant Mrs C did not know about current and future treatment options, but we have not found any indication the cancellation of the operation could have been avoided. We consider the Trust has already done enough to put right the impact of these events.
19. We appreciate the time Mrs C has spent in bringing her complaint to us and discussing her experience. We are sorry to hear about what happened and how this affected her.
20. Mrs C was scheduled for a shoulder operation in April 2020. This was cancelled due to the pandemic and not rescheduled because she was seen by a different consultant who recommended a different treatment pathway instead of surgery.
21. She is also concerned the Trust did not tell her the orthopaedic services were transferred to Hospital A.
22. Mrs C says the lack of communication about current and future treatment options meant she did not receive any treatment at all and was in pain for a prolonged time.
23. On 17 March 2020, NHS England wrote to all Trusts and GP practices advising to postpone all non-urgent elective operations from 15 April for a period of at least three months. This was done to ensure hospitals were able to handle any influx of patients that may need care and treatment for COVID-19, and to reduce the risk of hospital acquired infections.
24. The NHS England roadmap outlines the plans for restarting all planned procedures, including surgery. It advised specialists to prioritise those with the most urgent clinical need. Since the beginning of June 2020 some hospitals started to offer elective surgery, but this was considered based on clinical need.
25. The Trust has said in its final response, dated 20 January 2021, it had taken steps to deal with the backlog of patients waiting for elective services by moving some of its services to different sites. Hospital B and Hospital A are at different sites with different specialities but are part of the Trust. Mrs C has visited all three sites for assessments of her shoulder pain.
26. During the pandemic, the Trust developed surgical hubs as a temporary service to get through the backlog of waiting patients. It confirmed that when this was available it sent out a communication through its community leaders. It apologised that this was not effective and is sorry Mrs C did not hear about this.
27. The Trust acknowledged, in its final response, that Mrs C attended Hospital A in October 2020 and was not given a date for surgery. During this time the Trust implemented the national guidance on prioritisation for elective surgeries. It said it hoped Mrs C would be a priority but could not give an exact timescale of when her surgery would be.
28. The Trust provided a further response, dated 30 June 2021, where it explained more about how the surgical hubs worked. It confirmed the surgical hub for orthopaedics, however, it was not suitable for those who have complex health needs. It said the team who assessed Mrs C said if she was operated on, she may need high dependency support post-surgery and the surgical hub could not offer that due to its limitations caused by the pandemic. It confirmed she remained on a waiting list.
29. The Trust has apologised for the long wait and accepted it should have done better in updating Mrs C by telephone.
30. Guidance by the Federation of surgical prioritisation in the recovery from the Coronavirus pandemic splits patients into five categories: · Priority 1a – emergency procedures to be performed in <24 hours · Priority 1b – procedures to be performed in <72 hours · Priority 2 – procedures to be performed in <1 month · Priority 3 – procedures to be performed in <3 months · Priority 4 – procedures to be performed >3 months
31. Our adviser explains that during April 2020 certain procedures were cancelled due to the pandemic and the effects it had on the NHS overall. Each Trust had a different backlog of patients to deal with. However, to structure this, the NHS prioritised procedures based on clinical need.
32. The medical records show Mrs C had shoulder pain but with no specific tear which means she was not considered a priority, according to the guidance above, and this explains why she did not have the surgery in 2020.
33. We understand this will be frustrating for Mrs C to learn as she was in pain for a prolonged period.
34. Our adviser confirms the length of time someone is in pain is not a factor when categorising a patient as a priority. Prioritisation is based on clinical needs and risk. Our adviser says Mrs C falls within ‘priority 4 Hand and Upper limb surgery’ and this meant it could take over three months for her to be scheduled in for surgery.
35. Based on this, there are no indications of failings in the surgery not being offered sooner. It was in line with the guidance that she was not a priority patient and considered high risk.
36. It is clear the pandemic affected the cancellation in April 2020, and this was the case for the NHS nationally. We know this impacted on the level of service provided and this is not to detract from Mrs C not receiving the service she should have. We are incredibly sorry to hear about how she has been affected.
37. Prior to the pandemic, Mrs C’s surgery would have gone ahead at a hospital with suitable inpatient facilities.
38. Mrs C was signed off for surgery before the pandemic, and the criteria above regarding the surgical hubs did not exist then. Her risk level changed during the pandemic. Her surgery could not go ahead as she was considered high risk due to other health conditions she had, such as sleep apnoea.
39. Even if Mrs C knew about surgical hubs, she was not suitable for them as there was a possibility she needed inpatient facilities in the event of a complication.
40. Our adviser says she was considered high risk (due to existing health conditions) but also a low priority (shoulder pain with no tear), this meant she was unlikely to get the surgery anytime soon or in the time of the events complained about.
41. NHSE guidance, good communication with patients waiting for care (May 2021), says delays and any changes in treatment should be communicated with patients, and clinicians should be clear, honest and compassionate.
42. Our adviser has reviewed the medical records thoroughly and identified Mrs C saw numerous consultants over the period complained about. The reasons for this are unknown but it may be down to people leaving or staff unavailability. In October 2021 a consultant at the Trust said she would not benefit from surgery and instead offered her physiotherapy.
43. Our adviser explains the notes show when a new consultant saw Mrs C for the first time, they assessed her again and agreed a different plan for treatment, and they do not necessarily have to agree with the previous diagnosis or plan. If a patient sees the same consultant, they will receive treatment quicker and be aware of the treatment plan.
44. The National library of medicine, subacromial shoulder pain (March 2015) says: · ‘In the absence of a rotator cuff tear, if impingement symptoms fail to resolve with conservative treatment, subacromial decompression surgery (acromioplasty) is recommended · Subacromial decompression (acromioplasty) surgery aims to excise the bony spur on the antero-inferior surface of the acromion. The operation also involves excision of bursal tissue on the under surface of the acromion and release of the coracoacromial ligament. The procedure aims to increase the volume of the subacromial space, thereby reducing the mechanical attrition and painful irritation of the rotator cuff tendons’.
45. Our adviser explains the treatment options depends on each patient’s clinical symptoms and the guidance above applies to Mrs C. We know from the records she has been having shoulder pain since 2017, and had two injections that relieved pain. Since then, Mrs C has had physiotherapy which is another form of treatment to help manage the pain. The options for surgical or non-surgical treatment would depend on the assessment by the treating physician, their experience and practice, in line with GMC good medical practice.
46. The guidance also places great emphasis on shared decision making with the patient and how this can be achieved through direct consultation with them. The guidance also refers to the below:
47. The GMC’s Good Medical Practice guide clearly states, in the section on working in partnership with patients, that doctors should: · ‘listen to patients and respond to their concerns and preferences · give patients the information they want or need in a way they can understand · respect patients’ right to reach decisions with the doctor about their treatment and care · support patients in caring for themselves to improve and maintain their health’.
48. We are not critical of the cancelled operation because even if the Trust had communicated with Mrs C, she would not have been suitable for surgical hubs. This meant it was unlikely she would have had her surgery in 2020/ 2021, as established above.
49. However, we do consider the communication could have been better and it is reassuring to see the Trust has accepted and reflected on this.
50. Overall, the poor communication meant Mrs C did not know her treatment options, but we cannot say this has led to delays in her treatment due to the effects of the pandemic and the prioritisation guidance that was in place. We have seen no evidence in the records to show the Trust has explained this to her, or that her expectations were managed. This is not in accordance with the guidance above.
51. We go on to consider how the lack of communication impacted Mrs C and the action the Trust took.
52. We understand it was difficult for Mrs C to cope with her pain and how it affected her daily activities, and we are sorry for the distress these events caused her.
53. We also understand that not knowing about future treatment options added to Mrs C’s frustration and stress.
54. The Ombudsman’s Principles for remedy give an appropriate range of remedies where maladministration (fault) or poor service has led to an injustice. These include an apology, explanation, and acknowledgement of responsibility, revising procedures to prevent the same thing happening again, and training or supervising of staff. The principles also say organisations should ensure lessons learnt are put into practice.
55. The Trust explained that its elective services were moved to one location, and this was implemented nationally during the pandemic. The Trust has however recognised its lack of communication fell below the standards it expects and has apologised for how this impacted Mrs C.
56. Because of this complaint, the Trust has confirmed it has reviewed the patient waiting list and ensured it has updated everyone. It has apologised this was not available when Mrs C was seeking an update.
57. It is reassuring to see the Trust has reflected upon Mrs C’s complaint and understood the impact this had on her.
58. Having carefully considered the medical notes and the advice we have received, the lack of communication about treatment options during 2020/2021 did not delay her treatment.
59. We acknowledge Mrs C was in pain while she waited for updates about her surgery and we do not underestimate how difficult this must have been. We must also factor in the delay and lack of communication she experienced was also due to the pandemic, backlog of patients, and how she was prioritised. We have found she was prioritised correctly.
60. Our adviser explains Mrs C had a chronic condition, which consisted of pain in her shoulders since 2016, and it is unlikely these further delays would have made her pain any worse. Even if she had surgery in April 2020, we could never say for certain her pain would have been cured and we cannot hold the Trust accountable for this.
61. We also established Mrs C would not have met the criteria for surgery in 2020/2021 due to being high risk. Then, when she was assessed by another consultant, who said she would not benefit from surgery and recommended physiotherapy. We consider this to be part of the investigatory process into assessing Mrs C’s pain and we are not critical of the Trust’s actions here.
62. We understand the Trust’s lack of explanation meant Mrs C did not know what would happen in the future. The action the Trust has taken because of this complaint shows it has taken Mrs C’s concerns seriously and understood where it has gone wrong.
63. This is in accordance with our Principles of remedy, and we would not ask the Trust to do anything further in this instance.