Cyst removal operation
17. 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 that something has gone wrong.
18. Mrs U told us that when she saw the surgeon on 26 June 2023, she requested that her hair was not shaved during the procedure. Mrs U remembers signing a consent form but says she did not really take in its contents because she had had this operation several times before.
19. Mrs U told us how upset she was when she woke up from the operation and realised three areas of her hair had been shaved and only three of the 18 cysts had been removed.
20. Mrs U’s hospital records show she attended a pre-operation clinic on 10 February 2023 where it was noted there were multiple lesions (cysts) and that like before, she would have a general anaesthetic for the procedure. It is noted the main cysts were on the right shoulder and scalp and the risks and benefits were discussed.
21. On 26 June 2023 the medical records have several notes. These show Mrs U met the surgical and anaesthetic team and agreed to the procedure. There is reference to Mrs U not being happy with the discussion with the surgeon. A retrospective record of the pre-operative discussion (written after the discussion) notes the surgeon told Mrs U they may need to shave her hair to access the cysts and they would remove as many as was safe.
22. There is a note that the surgeon discussed Mrs U’s concerns with her. She said she thought she was going to be left with a hole in the head. The surgeon explained that this was not the case, but that sometimes due to different issues it is not possible to remove all lesions. It is documented Mrs U was happy to proceed.
23. The post-operative records show Mrs U was unhappy that some of her hair had been shaved and not all the cysts were removed. The surgeon reviewed her in the early evening and Mrs U said she was not told that her hair would be shaved and this had not happened before.
24. The surgeon spoke to Mrs U again later that evening. Mrs U complained that the Trust did not remove enough lesions and had shaved too much hair. The surgeon said both these issues had been discussed before the operation and that morning and Mrs U had been made aware that it may not be possible to remove all lesions in one session.
22. The Trust’s complaint response says that Mrs U was told that they may have to shave her hair to access the cysts. Also, the surgeon said dependent on the location of the cysts, they may be unable to remove them all at once. This is due to different factors including size and location of the cysts, movement of the scalp to allow safe closure and healing and safe anaesthetic time.
23. We asked our adviser whether the cysts could have been removed without shaving Mrs U’s hair.
24. Our adviser explained that in theory cysts can be removed without shaving the hair, but standard good surgical practice is that shaving is preferred. This is because if the hair is not shaved, the surgery is more challenging.
25. To get some reassurance for Mrs U we asked our adviser whether there was any clinical reason why shaving hair is preferrable. Our adviser explained that if the hair had not been shaved near each lesion: • it would be more difficult to identify and mark the lesion to be operated on • it makes it more difficult to suture (sew up) the wound • it makes it more difficult for wound management after the operation • it is more likely that hair would become matted around the operation site • it would be more likely to get infected • post-operative monitoring to identify potential infections would be more difficult.
26. The WHO safe surgery guidelines say hair should not be removed before surgery unless it will interfere with the operation. As explained by our adviser, there are signs the surgeons decided to remove some of Mrs U’s hair because it would interfere with the operation and may increase the risks both during the operation and during the recovery period. We see no reason to criticise the Trust’s actions in shaving some of Mrs U’s hair.
27. We also asked our adviser whether there was any reason why some cysts were left untreated despite the head being shaved. They explained that although the photos in the medical records are slightly blurry, there does seem to be a lesion in an area that had been shaved.
28. They explained it is not possible to say why hair was shaved but the cyst was not removed. They said there can be a number of reasons why an area is shaved and the lesion is not removed. These reasons include safe anaesthetic time and movement of the scalp during the operation.
29. We looked at the records for further information. The operation notes describe that during the pre-operation consultation on 26 June, the clinical staff explained to Mrs U that not all cysts might be removed due to safety constraints. The medical notes also state it was explained to Mrs U that she would not be left with a hole in the head but that sometimes, ‘due to various constraints it is not possible to remove all lesions’. It is noted that Mrs U was happy to proceed.
30. The Trust’s complaint response explains that Mrs U was told that some cysts might not be removed due to a number of factors as explained above.
31. We recognise the Trust has not given a clear reason why it decided not to remove all Mrs U’s cysts. Having reviewed the medical notes and the information the surgeon gave to the Trust’s complaints department, we are unfortunately not able to offer any further explanation to Mrs U. We recognise this will be frustrating and disappointing for her.
32. We hope Mrs U is reassured that there are important safety reasons why surgeons must sometimes do multiple cyst removal procedures when there are many cysts. GMC good medical practice says doctors must provide a good standard of care and contribute to systems to keep patients safe. We have seen no evidence of any failings in the Trust’s decision to finish the surgery without removing all Mrs U’s cysts.
33. Overall we see no signs of failings. This is because for cyst removal it is good surgical practice to shave the hair. We also have seen no reason to criticise the Trust for not removing all of Mrs U’s cysts.
34. We understand this is a difficult time for Mrs U and we hope this information goes some way in explaining what happened and why.
Complaint handling
35. Mrs U complains the Trust did not listen to her concerns. She felt the investigation was very unfair and that the complaint investigator had already judged her.
36. Our guidance says there may be times when we decide not to investigate because an investigation may be impractical or we would be unlikely to reach a satisfactory conclusion. We have looked at the available evidence and have decided there is not enough evidence for us to look at this issue fully and be able to make a decision on what happened.
37. We have seen the Trust acknowledged Mrs U’s complaint on 30 June 2023 and explained the timeframe for a response would be 25 working days.
38. On 19 July Mrs U emailed the Trust to ask for an update and the Trust responded by email the next day saying that complaints have a timeframe of 25 working days so a response is due by 4 August.
The person investigating the complaint got comments from the surgeon. They asked why the hair was shaved, why some cysts not removed and why all the cysts were not removed.
A complaint response dated 2 August was emailed to Mrs U on 3 August.
39. Our principles say organisations should deal with complaints quickly and sensitively, bearing in mind complainants’ individual circumstances. It also says that organisations should treat complainants impartially and make sure complaints are investigated thoroughly and fairly to establish the facts.
40. While the complaint response could have been more empathetic, it does address Mrs U’s concerns.
41. The Trust says sorry that Mrs U was unhappy with the surgeon’s communication on the day of surgery and for the distress Mrs U experienced.
42. Mrs U says she had a conversation with the person investigating the complaint before the response letter from the Trust. Mrs U says they commented they had worked with the surgeon for three months and was very surprised with the allegation. Mrs U felt the complaint investigator did not seem to believe what she told them.
43. The conversation is not shown in the Trust’s complaint file. We see an email dated 19 July 2023 from Mrs U to the complaints team mentioning the call. We do not dispute that the conversation happened, but we cannot say exactly what was said or if the investigator acted appropriately.
44. The Trust did get details from Mrs U, the surgeon and it reviewed the operation notes. This suggests a fair investigation. We recognise Mrs U will always have doubts after her conversation with the complaint investigator. Due to a lack of evidence we cannot investigate this further.
45. We appreciate going through the complaints process can be a stressful experience. We thank Mrs U for bringing her concerns to our attention.