Circle Health Group

6. Mr N complains the Group failed to properly prepare for the removal of a 15cm lipoma from his shoulder, in the months leading up to surgery on 20 April 2022. He also complains the Group discharged him on the same day without any aftercare advice and the wound stayed unhealed until he had it removed by another hospital in August 2022.

7. Mr N says the Group did not identify that he would need a specialist surgeon. He says staff prepared the incorrect anaesthesia (medicine to either numb the area or put a patient to sleep for surgery) so surgery had to be abandoned once an incision had been made. He said this caused him anxiety, distress and upset. He says he could not live his normal life, exercise and it ‘nearly ruined his relationship’.

8. Mr N wants a financial payment and service improvements.

9. In early 2021 Mr N noticed a fast-growing lump on his left shoulder. He says it continued to grow gradually until it was removed. In June he reported the lump to his GP. His GP referred him to the Group for an MRI scan (a scan that produces detailed images of the inside of the body). Mr N went to a consultation at the Group on 11 November and it did the scan on 18 November.

10. Mr N had a follow-up call with the Group on 15 December. It said the lump was a lipoma and measured 8cm by 5cm. It said it would arrange surgery within 16 weeks to remove it.

11. Mr N went to the Group on 20 April 2022 to have the lipoma removed. The Group had planned to do the surgery with a local anaesthetic, but because of the size of the lipoma it decided general anaesthetic would be better. Mr N waited a number of hours before the general anaesthetic was given and the surgery could start. Once the surgeon made an incision to remove the lipoma, they realised it was surrounded by muscle, veins and nerves and the surgery would need to be done by a specialist surgeon.

12. Mr N was discharged from the Group on the same day to wait for the surgery to be rearranged. A specialist surgeon removed the lipoma on 18 August.

Preparation for surgery

16. Based on the Group’s MRI scan report, Mr N’s lump seemed to be an intramuscular lipoma. An intramuscular lipoma is a rare but non-cancerous tumour that forms deep inside the muscle.

17. The Group called Mr N on 15 December to discuss his MRI scan results and it said a general surgeon would remove the lipoma.

18. Our adviser says the Group should have referred the case to a sarcoma multi-disciplinary team (MDT) for review (an MDT is a meeting made up of professionals from different areas of medicine). This is in line with BSC guidelines that say: ‘patients with soft tissue masses with any of the following features should be referred urgently to a sarcoma multi-disciplinary team (MDT) for investigation and management: • increasing in size • size more than 5 cm (except superficial subcutaneous lipomas) • painful.’

19. It was a failing to not refer Mr N’s case to an MDT because of the lipoma’s size.

An MDT would have identified that his lipoma was surrounded by muscle and blood vessels and it would need to be removed by a specialist surgeon.

20. Mr N went to the Group for the removal of his lipoma on 20 April 2022. The Group had planned to use a local anaesthetic but it decided a general anaesthetic should be used. This caused a delay to the surgery.

21. The RCS guidance says: ‘surgeons should apply their clinical skills, knowledge and experience to practice and should: • When providing elective care for patients with non-urgent conditions, carry out procedures that lie within the limits of your competence and the range of your routine practice, and refer where necessary • Carry out surgical procedures in a timely, safe and competent manner, and ensure that you follow current clinical guidelines in your field • Use the skills and knowledge of other clinicians. When the complexity of the procedure is an issue, you should consider shared decision making and shared operating with another expert consultant colleague. When appropriate, you should transfer the patient to another colleague or unit where the required resources and skills are available.’

22. Our adviser explained the MRI scan clearly showed Mr N’s lipoma was located within his shoulder muscle. The surgeon should have known the surgery was going to be complex because of this.

23. WHO guidelines for safe surgery include a surgical safety checklist. It says imaging is critical for proper planning of operations. According to the checklist, before a skin incision, the coordinator should ask the surgeon if imaging is needed for the case. If so, the coordinator should verbally confirm that the imaging is available and visible in the room during the operation.

24. The Group did complete the WHO safety checklist but we note it marked the imaging section as ‘not applicable’. This shows the imaging was not considered before surgery. The Group says the surgeon looked at the imaging before surgery. The records do not support this. As explained by our adviser, this would have been another opportunity for the surgeon to consider the MRI scan and recognise that the lipoma was within the shoulder muscle and that a specialist surgeon would need to operate.

25. The Group did not follow guidance when preparing for the removal of Mr N’s lipoma. The surgeon did not have the skills needed to do this surgery and had to stop the procedure after making an incision. This means Mr N had an unnecessary procedure and experienced problems with his wound healing while he waited for more surgery.

26. Mr N waited 17 weeks before the surgery was rearranged. Our adviser said after surgery was stopped, the lipoma continued to grow which caused pressure on the location of the incision. This is likely why Mr N had problems with the wound healing. Mr N would not have had these problems if the incision had not been made before surgery was abandoned.

27. Mr N says he lived for four months with an unhealed wound that stopped him from living his normal life. He explained he could not exercise as he usually would because the wound caused him pain and he had to wear a t-shirt on holiday. He says it affected his mental health and he was extremely low during this period, as he was still unsure if his lipoma was cancerous. He also says it nearly ruined his relationship.

28. In its complaint response the Group apologised for stopping Mr N’s surgery. It did not acknowledge its lack of preparation for surgery or recognise that a specialist surgeon was needed from the beginning. It has not accepted that this meant Mr N had a wound that did not heal for 17 weeks.

29. We do not think the Group has done enough to put things right for Mr N. We uphold this part of the complaint and at the end of this report we explain what action the Group needs to take.

Wound care advice

30. Mr N says after his surgery on 20 April 2022 the Group discharged him on the same day without any wound care advice.

31. NICE guidance says healthcare professionals should:

• ‘offer patients and carers information and advice on how to care for their wound after discharge • offer patients and carers information and advice about how to recognise a surgical site infection and who to contact if they are concerned • use an integrated care pathway for healthcare-associated infections to help communicate this information to both patients and all those involved in their care after discharge’.

32. We have seen evidence that on 18 August 2022 Mr N’s surgical wound was ‘still scabby’.

33. The RCS guidance says surgeons should make sure patients get good post-operative care, and that relevant information is recorded quickly and shared with the relevant teams, the patient and their supporters.

34. We looked at Mr N’s discharge records. The Group did not complete the discharge advice section in Mr N’s medical records or the discharge documents. This means there is no evidence of the Group giving wound care advice. Mr N told us he did not know where to go for help, which suggests the Group did not give advice before it discharged him.

35. We have decided the Group did not give Mr N any wound care advice.

If the Group had given Mr N appropriate wound care advice he would have known he needed to get medical advice when his wound did not heal and that his surgery might need to be moved forward.

36. The poor condition of the wound could have meant he was able to have surgery by a specialist surgeon earlier. He would also have felt less distressed by his condition and had more confidence that he was being monitored and treated. His pain could also have been managed better.

37. We do not think the Group has done enough to address this failing or the impact it had on Mr N. We uphold this complaint and below have explained what action the Group should take.

1. We understand Mr N is concerned the Circle Health Group (the Group) did not correctly prepare for the removal of his lipoma (a non-cancerous tumour made up of fat, usually formed between the skin and the muscle) in April 2022. He thinks this means the wrong surgeon was arranged and his surgery was abandoned leaving him with an open wound that did not heal properly until after a second surgery.

2. We found the Group’s preparation for the removal of Mr N’s lipoma was not in line with guidelines. We went on to consider if this impacted on what happened and the outcome for Mr N.

3. We found the Group’s preparation for Mr N’s lipoma surgery meant a general surgeon was arranged and his surgery was abandoned after an incision (cut) had been made. The Group has noted and apologised for the fact Mr N’s surgery was abandoned. It has not accepted this was due to a failing in preparation, or that two different surgeries and a long delay with an open wound could have been avoided. For these reasons, we uphold this part of the complaint.

4. We have also considered Mr N’s complaint about the lack of wound aftercare advice the Group gave him. We found the Group did not follow guidelines to give Mr N appropriate wound aftercare advice and it did not complete relevant discharge advice documents. This meant Mr N was left for 17 weeks with an unhealed wound and he was unsure who to contact for advice. We uphold this complaint.

5. The Group did not acknowledge these failings. We recommend it provide Mr N with an acknowledgement of its failings, an apology and that it makes a compensation payment of £1,100. We also recommend the Group produces an action plan to show how it will learn and improve.

38. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.

39. Our Principles say organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service.

40. In line with this, we recommend the Group: • writes to Mr N to apologise for the failings we have identified in preparing for the surgery and failing to give good wound care advice. It should apologise for the concern and distress this has caused him • completes an action plan to address the failings we have identified. The action plan should include the action, who is responsible for it, the timescale for completing the action and how it will be checked to make sure improvements are made.

41. Our Principles say organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should pay them appropriately.

42. To decide on a financial payment, we review similar cases where a person has experienced similar injustice. We recommend the Group pays Mr N £1,100 in recognition of the unnecessary surgical procedure he had, the worry and distress he experienced because of this, and the unhealed wound he had for four months.