Mrs T complains she was incorrectly treated by the Trust for a problem to her left knee leading to a delay in diagnosing her left hip.
19. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened in line with relevant standards and guidance with what did happen.
20. We have identified a short delay in carrying out a hip examination. This should have occurred on 3 February 2020 and finally did on 17 February 2020 but have identified no impact from this. We also identified a problem with record keeping which did not record the hip examination during the consultation of 17 February. We consider this has been acknowledged and remedied by the Trust. Therefore, we have decided to take no further action with this part of the complaint.
21. To establish ‘what should happen’ we refer to guidance by the National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG177) Osteoarthritis: care and management. Section 1.1 of this guidance says:
‘Diagnose osteoarthritis clinically without investigations if a person:
· is 45 or over and
· has activity-related joint pain and
· has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.’
22. Section 1.2.5 of this guidance says clinicians should offer advice on the following core treatments to all people with clinical osteoarthritis.
· ‘Access to appropriate information
· Activity and exercise
· Interventions to achieve weight loss if the person is overweight or obese’
23. The guidance says in section 1.6, clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options as recommended in section 1.2.5.
24. We also considered the Chartered Society of Physiotherapy (CSP), Quality Assurance Standards 2013. These outline the expected requirements of good physiotherapy service provision. These guidelines are broken down into various sections and the relevant sections for this complaint are section 6, Record keeping and information governance and section 8, Physiotherapy management and treatment.
25. Section 6.1 says every service user who receives physiotherapy has an appropriate record. The criteria to meet this standard are records:
· ‘are started at the time of the initial contact
· written immediately after the contact with the service user or before the end of that working day
· include a reference in each entry to the date and time of treatment or advice
· include a reference to the date and time that the entry into the record was made
· are legible, factual, consistent, and accurate such that service users and other health professionals can understand the content
· are attributable to the individual completing them
· provide evidence of the care planned, the decisions made, the care delivered, and the information shared
· identify problems that have arisen, and the action taken to rectify them
· provide evidence of actions agreed with the service user (including consent to treatment and/or consent to disclose information)
· are written, wherever appropriate, with the involvement of the service user
· use standard coding techniques and protocols for electronic records where appropriate’
26. Section 8.3.3 of the standards is there is written evidence of a physical examination carried out including measurable data which includes:
· ‘observation
· use of specific assessment tools/techniques
· handling/palpation’
27. The Trusts local policy says its physiotherapists cannot arrange for further investigations or surgical review. It says following assessment they will arrange alternative treatment options such as physiotherapy exercises, guided injections, or referral to another specialty or ESP Clinic.
28. Mrs T tells us she was experiencing a lot of pain in her left knee, so she arranged to first attend the Trust for a physiotherapy assessment on 3 February 2020. She says she was then referred to a one-to-one rehabilitation session on 17 February and it was at this appointment she informed the physiotherapist she was struggling carrying out the exercises due to her hip pain. Mrs T says she then asked for an X-ray or scan of her hip and the physiotherapist examined her hip and told her she had a full range of movement in it, and her hip was not the problem therefore further clinical investigations were not necessary.
29. Mrs T says as the exercise therapy was not helping, she agreed with the physiotherapist to have a steroid injection, which she tells us caused her added pain and discomfort and was not necessary.
30. Mrs T tells us she received a letter in December 2020 saying her appointment at the ESP Clinic was arranged for 4 June 2021. However, fifteen months from her first physiotherapy session, due to her ongoing pain and the impact this was having on her day-to-day activity, she went to see her own GP in early May 2021. They carried out an examination to her hip, said that was the problem and referred her for an X-ray. The appointment for the X-ray was scheduled for 17 June 2021.
31. At her appointment at the Trust on 4 June 2021, Mrs T says the ESP arranged for an X-ray of her left knee and upon reviewing the X-ray they said her knee was not the problem.
32. Mrs T was then sent back to have an X-ray on her left hip and the ESP reviewed this and explained there was deterioration to her hip joint, and they would not refer her for physiotherapy or steroid injections as this would not help. Mrs T says the ESP said the physiotherapists she had seen previously should have known that pain in the knee can be pain referred from the hip.
33. During the period from February 2020 to May 2021 Mrs T had been relying on over-the-counter medicines to her manage pain and had not sought further consultation with her GP and had been following the physiotherapy. Mrs T say she cannot understand why the physiotherapists at the Trust were unable to identify her knee pain was in fact caused by her hip problem and then arrange for appropriate tests and treatment for her hip. Mrs T believes if she had been diagnosed sooner, she would have had her hip replacement surgery by now.
34. In its complaint response the Trust said Mrs T’s pain was recorded as being localised to her knee when she attended the physiotherapy assessment. It said Mrs T gave her history of her attending A&E in 2012, when her knee gave way and showed signs of swelling, and this gave a potential diagnosis of a torn cartilage in the knee. The Trust says Mrs T was examined by the physiotherapist at the assessment and it is recorded there was significant loss of knee movement and Mrs T was referred to attend a rehabilitation programme with a physiotherapy assistant.
35. The Trust letter said other joints were examined in February during Mrs T’s treatment and not thought to be contributing to her knee problem and this would include the hip joint, however it did not specify details of this examination in the medical record.
36. The Trust said it had followed the NICE clinical guidance for osteoarthritis and its own local pathways for referral for surgery. It explained the physiotherapy assistant is not a trained physiotherapist and manages the rehabilitation programmes. It also said, in line with its local policy, the physiotherapists at the Trust cannot make recommendations for surgery, they can only refer patients to the ESP Clinic when conservative treatment is not effective.
37. The Trust explained Mrs T was referred to the ESP Clinic in October when she attended an assessment and told the physiotherapist of her ongoing knee pain, and she would consider a surgical review. The referral was made to the ESP Clinic to review her knee problem on the understanding she had osteoarthritis to her knee.
38. The Trust apologised to Mrs T for her experience and said from assessment and examination the physiotherapists involved in her treatment concluded that at the time her problem was related to her knee.
39. It said a hip X-ray was not felt necessary in February 2020 as the hip had been examined, and then excluded, as the possible problem. It also said all involved in her care had learned from her complaint in that they would be more explicit in writing up notes.
40. From the evidence we can see Mrs T attended the Trust on 3 February, 17 February, and 29 October 2020 and again on 4 June 2021.
41. The record of the assessment on 3 February says Mrs T presented with a history of left knee pain. It is noted she sought medical attention in 2012 after her knee gave way. The notes say she advised of having an MRI scan and this showed torn knee ligaments and mild osteoarthritis. Mrs T reported her knee had improved following this incident, but she had mild consistent pain since.
42. The records show Mrs T’s knee was examined and based on the information she provided, the outcome of her physical examination, and her limited range of movement due to pain. The physiotherapist recorded an acute flare up of tricompartmental osteoarthritis to the left knee (the knee joint consists of three parts. Tricompartmental osteoarthritis occurs when arthritis symptoms affect all three parts). As Mrs T had reported her pain had been getting worse over the last year, she was advised about seeking pain relief from her GP and to attend one-to-one physiotherapy rehabilitation treatment at the Trust.
43. From clinical advice, and in line with CSP guidance, it would be expected that an examination should have been carried out to identify or rule out any hip problem. This is because pain presenting in the knee area may be a sign of a problem with the hip as pain from the hip can radiate down to the knee. This is known as referred pain, however pain from the knee does not radiate up to the hip.
44. The records show, in line with the guidance, that an examination of the left knee was carried out, however there is no record (taken at the time) that, in line with the guidance, Mrs T’s hip was examined at the assessment on 3 February 2020.
45. The records from 17 February show Mrs T as unable to complete the exercises due to the pain she was experiencing in her left knee and groin. The physiotherapy assistant completed the notes and recorded Mrs T had spoken to the physiotherapist about her pain and agreed to have a steroid injection in her knee.
46. There is no note on the records of the physiotherapist examining Mrs T’s hip or about Mrs T asking for further tests. However, from the information provided by Mrs T and the Trust, we accept the examination of Mrs T’s hip did take place at this time on the 17 February. This is when she was informed by the physiotherapist her hip was not the problem. We understand it was after this examination that Mrs T consented to have a steroid injection.
47. We can see from the records Mrs T had a steroid injection to her left knee on 11 March at the Trust. It says review in two weeks which would be around 25 March.
48. From the information available we consider there has been a deviation from Section 8 of the CSP guidelines in that Mrs T’s hip was not examined at her physiotherapy assessment on 3 February, as the consideration of the knee should have also included wider consideration of the hip.
49. However, we understand an examination of her hip was undertaken two weeks later, on 17 February, when she attended her physiotherapy rehabilitation session. The findings of this examination were Mrs T had a full range of movement and further tests were not indicated at this time.
50. We do not consider this short delay of examining Mrs T’s hip had any impact on her ongoing treatment as by the next appointment on 17 February, there were no problems identified with the hip when both the hip and knee examined at this date. On the balance of probabilities, where something is more likely than not to have happened, it is our view that if the consultation on 3 February included a hip examination the findings would have been the same. From this consultation the appropriate treatment plan for Mrs T’s knee pain was continued.
51. We have also found there has been a deviation from Section 6 of the CSP guidelines in record keeping as the examination of Mrs T’s hip was not noted in the medical record of 17 February. However, we are pleased to note the Trust and Mrs T have acknowledged the examination did take place and the Trust apologised the record was not completed. It has also explained the staff involved have learnt from this complaint to be more thorough in record keeping.
52. Record keeping is, however, not part of the complaint we have been asked to look at, so we have not further gone onto reach a view on this or the suitability of the remedy, in line with our Principles for Remedy.
53. From the evidence available we consider the clinical treatment provided to Mrs T was appropriate and in line with the NICE guidelines. Mrs T presented with knee pain and no examination of her hip was undertaken on 3 February. Though we know from the later examination of her hip on 17 February there were no presenting problems, so cannot say there is an impact of that missing examination. We can see Mrs T was then referred for exercise therapy and then an injection before surgery was considered for her knee problem. Following examination of her hip, no problem was identified.
Mrs T complains of a delay of 18 months in diagnosing a problem to her left hip.
54. The National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG177) Osteoarthritis: care and management is also relevant for this part of the complaint.
55. Section 1.2.5 of this guidance says clinicians should offer advice on the core treatments to all people with clinical osteoarthritis. These are access to appropriate information, activity and exercise and interventions to achieve weight loss if the person is overweight or obese.
56. The guidance also says in section 1.6, clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core treatment options as recommended in section 1.2.5.
57. We can see Mrs T had a steroid injection in her knee on 11 March 2020 and this is in line with NICE guidance. All core treatment options should be explored before the consideration of surgery.
58. The record from 11 March says review in two weeks. However, this was at the onset of the COVID-19 pandemic, which resulted in all elected care being postponed for many months. Mrs T’s next appointment at the Trust was another self-referred physiotherapy assessment on 29 October 2020.
59. It is recorded in the notes of the appointment in October that Mrs T said the effect of the steroid injection she had in March had only been felt for about two weeks. She reported she was still experiencing pain to left knee and it was giving way often which led to her falling. She said it was causing sleep disturbance every night and affecting her day-to-day activities, and she was happy to consider a surgical review.
60. The agreed plan was for the physiotherapist to refer Mrs T to the ESP Clinic as all other treatment options had been tried and this is in line with the NICE guidance. It says in the notes Mrs T was advised of the lengthy waiting times for an appointment at the ESP Clinic.
61. We understand Mrs T received her appointment for 4 June 2021 in a letter from the Trust dated 11 December 2020. We can see this is a long waiting time for an appointment to a clinic but recognise this was due to the backlogs of waiting lists. These built up during the first lockdowns when elected care was postponed due to the pandemic. Regrettably in the context of the pandemic this is something that occurred nationally, and we cannot be critical of this during that unprecedented time.
62. We recognise Mrs T has experienced ongoing knee pain for many years and this has gradually worsened and had a detrimental effect on her, limiting her mobility and carrying out day to day activities. We do not have any evidence of when Mrs T’s left hip began to deteriorate and cannot say this was the problem all along as Mrs T was first presenting with knee pain to the Trust. Nor, if we were to progress to a detailed investigation do we consider (in line with our own policy) that a further detailed investigation could provide us with independent impartial evidence to say with certainty when the deterioration occurred and its speed of onset.
63. From the evidence available we cannot conclude that Mrs T was incorrectly treated for a problem to her left knee, and this led to a delay in diagnosing her hip problem. She presented at the Trust with problem to her knee and was offered treatment in line with NICE guidance to pursue core treatment options before surgical consideration first.
64. Mrs T reported the injection to her knee in March had provided around two weeks relief which suggests it likely there was a problem with her left knee.
65. Mrs T had her hip examined by a physiotherapist on 17 February 2020 who told her she had full range of movement at that time so further investigations were not thought necessary. This is in line with the NICE standard. Based on this, we do not consider there were delays in providing the treatment as she was assessed and had a pathway of care, physiotherapy, and injection treatment within six weeks from 3 February to 11 March 2020.
66. Mrs T then sought medical advice from her GP on 4 May 2021, she was advised at this appointment it may be a hip problem and referred for further tests.
67. We understand Mrs T’s hip problem was first found following X-ray, during her appointment at the Trust on 4 June 2021, and in line with NICE guidance have seen the care pathway prior to this was appropriate.
68. While we recognise Mrs T has experienced pain for a considerable amount of time, based on the evidence available we do not consider there were any delays which can be attributed to the Trust in the care and treatment provided to her, and decided not to take any further action with this part of the complaint.