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University College London Hospitals NHS Foundation Trust

P-001887 · Statement · Decision date: 30 March 2023 · View University College London Hospitals NHS Foundation Trust scorecard
Complaint (AI summary)
Mr R complained the Trust incorrectly stated his torn pectoral muscle was inoperable and refused surgery, despite a second opinion confirming it was possible, leading to cosmetic asymmetry and mental health issues.
Outcome (AI summary)
The ombudsman closed the complaint, finding no signs of wrongdoing. The Trust's care was deemed to be in line with relevant standards, despite Mr R's concerns.

Full decision details

The Complaint

3. Mr R complains about the care and treatment he received from the Trust following a torn pectoral muscle (a muscle connecting the front of the chest with the bones of the upper arm and shoulder) in June 2021.

4. Mr R says the Trust incorrectly informed him his injury was inoperable, and it refused to operate following a second opinion from a private surgeon confirming a surgical intervention was possible.

5. Mr R says the Trust’s failure to operate increased the risk of his tendon retracting, causing a cosmetic asymmetry of his pectoral muscle. Mr R tells us this time was extremely stressful, negatively affected his mental health and led to the closure of his business.

6. Mr R wants financial compensation for the cost of surgery and for the Trust to accept its failure and to apologise.

Background

7. Mr R suffered an injury to his left pectoral muscle on 18 May 2021. He went to the emergency department on 19 May. On 29 May, he had a magnetic resonance imaging (MRI) scan (a type of scan using strong magnetic fields and radio waves to produce detailed images of the inside of the body). This confirmed an isolated rupture of the pectoral muscle.

8. While researching his injury, Mr R came across a study which showed it was operable, using an allograft reconstruction within two weeks of the injury to prevent tendon retraction and permanent damage.

9. On 1 June 2021, during a trauma multidisciplinary team (MDT) meeting to discuss Mr R’s injury, the Trust decided the muscle may not be surgically repairable due to the nature of the tear. The MDT agreed non-surgical treatment would be the best option. The Trust believed the results would be similar to a surgical treatment and would achieve an excellent functional outcome with good strength.

10. Mr R disagreed with the Trust’s decision to treat his injury non-surgically. He talked to a private surgeon on 7 June 2021 who confirmed a surgical intervention was possible. Mr R told the Trust he would prefer to have surgery rather than a non-surgical intervention.

11. On 11 June 2021, the Trust held a second MDT meeting to discuss Mr R’s wish to have surgery. The MDT again decided to offer a non-surgical approach to treat the injury.

12. The Trust offered Mr R the opportunity to get the opinion of another consultant orthopaedic surgeon (a specialist in diagnosing and treating bone and muscle conditions) at a different hospital. Mr R declined the offer and had private surgery to repair his injured pectoral muscle on 14 June 2021.

Findings

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.

Our Decision

1. The Parliamentary and Health Service Ombudsman has carefully considered Mr R’s complaint about University College London Hospitals NHS Foundation Trust (the Trust). We have decided to take no further action as we have seen no signs of any wrongdoing. Based on the evidence we have seen, the Trust has given care to Mr R in line with the relevant standards.

2. We are sorry to hear about Mr R’s injury and the impact it has had on him. We realise this has been a difficult time for him, and we thank him for giving us the opportunity to consider this complaint. We are sorry for any further distress our decision may cause and hope our explanations below show how we have fully considered his complaint.

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