16. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether there are signs the organisation has done something wrong. We do this by comparing what should have happened with what did happen. We have done this for Mr R’s complaint, and we have not seen any signs something has gone wrong.
17. We have not seen any maladministration (fault) or service failure in the Trust’s decision to offer non-surgical treatment to repair Mr R’s injured pectoral muscle instead of the surgical treatment he preferred.
18. In providing care and treatment to Mr R, the Trust has acted in line with GMC guidelines.
19. Mr R went to the Trust’s emergency department on 19 May 2021 after injuring his left pectoral muscle. He had an MRI scan on 29 May which showed an isolated tear of the ternal head (the upper section of the pectoral muscle).
20. The Trust held MDT meetings on 1 and 11 June 2021 to discuss treatment options, and it detailed the reasons for selecting a non-surgical approach to Mr R’s injury. The surgeon’s letter dated 28 July 2021 shows Mr R’s case was discussed at the upper limb MDT meeting on 11 June, when it was agreed the injury should be treated conservatively and non-surgically. The Trust offered Mr R a face-to-face, second-opinion appointment at another Trust hospital but he declined the offer.
21. Mr R saw a private surgeon on 7 June 2021, three weeks after the injury, and they discussed options including surgery. The letter from the private surgeon shows both non-surgical and surgical options were discussed. The surgeon told Mr R surgery would be unlikely to achieve total symmetry and they discussed the risks of surgery. While the private surgeon operated on Mr R shortly afterwards, they echoed the Trust’s opinion that either treatment would be suitable. The private surgeon outlined the limitations of surgery.
22. We have asked our adviser whether the Trust’s decision to offer non-surgical treatment only was appropriate. Our adviser says both surgical and non-surgical interventions are suitable for Mr R’s injury.
23. There is not enough data to suggest which option is more effective. Our adviser says sutures (associated with surgery) are not as effective on muscles as they are on tendons. However, patches have recently been used but there are no long-term studies to show how effective they are.
24. The evidence suggests both surgical and non-surgical interventions are effective methods of treatment for Mr R’s injury. There is no consensus of opinion on whether the outcome of surgical treatment is superior to that of a non-surgical approach.
25. It is not for us to question clinical decisions if we are satisfied these decisions have been taken in line with the guidance. We appreciate Mr R’s decision to opt for surgical treatment for his injury.
26. Mr R chose to have the surgery privately. However, the Trust was willing to treat the injury non-surgically, which, according to the evidence outlined above, is an appropriate method of treatment for this type of injury.
27. We have thoroughly and carefully considered all the evidence and reviewed what should have happened according to the guidance. The evidence suggests this type of injury can be treated surgically or non-surgically.
28. The Trust has followed the relevant guidance in treating Mr R’s injury. We have not seen any signs of failings, so we will not consider this matter further.
29. We recognise Mr R may be disappointed with our decision, and we are sorry for any distress this may cause. It is our role to remain impartial and transparent in explaining our decision. We hope Mr R understands our reasons.