16. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs something has gone wrong.
Delay in X-ray
17. BOA guidance says within the first course of post-operative care (care given after surgery), it should be considered standard practice for an X-ray to be done to make sure the position is right, that there is no evidence of bony injury or any unexpected concern.
18. Our orthopaedic adviser says an X-ray is done when it is safe and before a patient is discharged. The clinical records do not mention that a post-operative X-ray had to be done that day.
19. The clinical records show Mrs E had an X-ray on 19 July.
20. We understand Mrs E says there was a delay in the Trust doing an X-ray. The evidence suggests an X-ray should be done before discharge. We can see the Trust did an X-ray on 19 July and this was before Mrs E’s discharge. This is in line with guidance.
Being given ice after surgery
21. Our orthopaedic adviser said there is no specific guideline about the use of ice after knee surgery.
22. There is no evidence in the clinical records that ice needed to be given to Mrs E.
23. Using cryotherapy (cold therapy) after total knee replacement studies say the certainty of evidence was low for blood loss, pain and range of motion and very low for transfusion rate, function, total adverse events and withdrawals from adverse events.
24. Our orthopaedic adviser explained the potential benefits of cold therapy on blood loss, pain and range of motion may be too small to justify the use of cold therapy.
25. We recognise Mrs E says she should have been given ice. The evidence suggests the surgeon did not leave instructions that ice was necessary. As there is no specific guidance to say ice must be given, we are unable to say the Trust did anything wrong. What we can say is even if ice was used, there is no evidence to suggest it has any benefits for recovery.
Ankle referral
26. In her complaint Mrs E says she was referred for ankle surgery in December 2019. Mrs E says she got a call in July 2022 saying the Trust had two procedures on their waiting lists for her and asked if she wanted the knee or ankle done. Mrs E says she chose the knee. She says she was not able to make an informed choice because she was not given all the information and was not told the consultant was retiring.
27. GMC guidance says doctors must work with patients, sharing with them the information they will need to make decisions about their care including their condition, its likely progression and the options for treatment including risks and uncertainties.
28. The clinical records show there was a phone consultation on 28 April 2021 with the consultant surgeon to discuss her options. It says the consultant talked about her options and that an ankle replacement was a good option for her.
29. The clinical records say the consultant went through what this involves and put her on the list for ankle surgery as there was quite a wait. The clinical records also say the consultant would see her in a few months’ time after she recovered from the knee surgery, before considering ankle surgery.
30. Our orthopaedic adviser says prioritising either ankle or knee surgery has to be done jointly with the patient and depends on the seriousness of the symptoms for each joint and which one was causing the most concern at the time. Our orthopaedic adviser said the decision could be reviewed if there was a change in circumstances. There is no evidence from the clinical records that there were any significant changes.
31. We do not underestimate the pain Mrs E was in while she was on the waiting list for ankle surgery. The evidence in the medical records suggests the decision to do the knee surgery rather than the ankle surgery was made jointly. We understand Mrs E says it was not informed consent. In situations like this it is difficult to say what happened, based on the records that were made at the time. We do not dispute Mrs E’s memory of events, but we cannot make a finding of failure on her account alone when the clinical records say something different. We think the Trust acted in line with GMC guidance.
32. NHS guidance says upon completion of a consultant led referral to treatment (RTT) period, a new waiting time clock only starts:
• when a patient becomes fit and ready for the second consultant-led bilateral procedure • upon the decision to start a new or different treatment that does not already form part of that patient's agreed care plan.
33. The clinical records show Mrs E was put on the waiting list for ankle surgery on 28 April 2021 and this procedure would not be done until she had recovered from her knee surgery.
34. The clinical records show Mrs E had this knee surgery on 18 July 2022, with a six-week post operative review on 31 August and a three month follow up on 19 October. Our orthopaedic adviser said this is when the 18 week-rule would begin again for the ankle surgery.
35. On 4 October, the clinical records show Mrs E had an appointment at another hospital about her ankle. This clinical letter says Mrs E got a referral to this hospital because the last surgeon had retired. Mrs E confirmed she asked her GP to do this referral.
36. We understand waiting for a surgical procedure can be stressful. The evidence suggests Mrs E was put on the waiting list for ankle surgery on 28 April 2021. As a joint decision was made to do this procedure after her knee surgery, the 18-week rule would apply from when Mrs E was fit and ready for the second procedure after her three month follow up on 19 October. This is in line with NHS guidance. As Mrs E asked for a new referral to a different hospital, we do not know whether she would have had her ankle surgery done at the Trust within the 18-week guidelines.
Catheter
37. RCEM guidance says short term catheterisation is the usual way of treating urinary retention (when you cannot completely empty the bladder).
38. Our nursing adviser explained acute urinary retention is a common complication after surgery, usually caused by the anaesthetic or the medications given while having surgery.
39. The clinical records show Mrs E had urinary retention after surgery and she tried to pass urine twice but could not. The clinical records show Mrs E’s urine was monitored over four hours, but it did not improve and more urine was collecting in her bladder. The nursing team decided to scan Mrs E’s bladder and it showed she had 840mls of urine that she was unable to pass.
40. RCN guidance says it is important that a patient is allowed to make an informed choice about the use of a catheter. This includes understanding the decision, alternatives and the consequences of not having one.
41. There is no evidence in the clinical records that suggests Mrs E did not want the catheter fitted. The catheter care records say it was informed consent.
42. We recognise Mrs E says she did not want a catheter. We can find no evidence in the clinical records that Mrs E did not want this procedure. This does not mean what Mrs E tells us is not correct. What we can say is there is medical evidence that Mrs E needed a catheter due to her urine retention. We think the Trust acted in line with RCEM guidance.
43. We thank Mrs E for bringing her complaint to us for consideration. We are sorry to hear of the time it took for her to have treatment and understand how difficult it must have been for her to go through the details of her complaint again.