MTWT
Cancelled surgery in August 2020
25. Mrs P says MTWT should not have delayed her daughter’s surgery because she was in pain while waiting for this. She has highlighted MTWT was completing surgeries during the time in question, and through an information request found it had completed 106 orthopaedic paediatric elective surgeries between 17 August 2020 and 28 February 2021.
26. MTWT said the impact of the COVID-19 pandemic delayed Miss P’s surgery. During this time, it said it suspended all non-urgent elective surgeries and re-arranged Miss P’s procedure as soon as possible. Elective surgery is surgery planned in advance and is not an emergency.
27. MTWT initially booked Miss P’s surgery for 17 August 2020, but it then cancelled this and the surgery instead took place on 17 May 2021.
28. NHS guidance from April 2020 on ‘surgical prioritisation during the coronavirus pandemic’ categorises surgical procedures from the most time-urgent emergency cases, to those needing an operation within 24 hours, to those cases that could be delayed for more than three months.
29. Our orthopaedic surgeon adviser has confirmed Miss P’s surgery fell under the category of ‘spasticity management and corrective surgery for established deformity’, and this was in the priority level of cases that could be delayed for more than three months.
30. We consider MTWT acted in-line with the NHS guidance for surgical prioritisation when it cancelled Miss P’s surgery at the start of the COVID-19 pandemic. This is because the type of surgery she was due to have fell within the category that meant it was not urgent and could wait more than three months.
31. On 31 July 2020, the NHS issued guidance to NHS trusts advising them elective services should now re-start. It advised that ‘clinically urgent patients should continue to be treated first’, and those who had been waiting the longest should be the next priority.
32. MTWT provided us with information showing the demand on its services during this time, including the numbers of children waiting for orthopaedic surgery. Our orthopaedic surgeon adviser has commented the numbers show the Trust had a backlog of cases that would likely have taken a significant amount of time to clear.
33. Our orthopaedic surgeon adviser has reviewed the evidence MTWT has provided that shows its planning for re-starting elective surgery and the numbers of patients it had waiting for paediatric orthopaedic surgery. They have said this information supports MTWT managed to re-schedule Miss P’s surgery appropriately in consideration of the constraints on its service.
34. We understand Mrs P has concern MTWT did not re-schedule her daughter’s surgery with sufficient priority once it started carrying out elective surgeries again, and she was aware procedures were taking place.
35. From the evidence we have reviewed and the advice we have received, we consider MTWT acted in-line with the July 2020 NHS guidance when re-starting its services. We have also seen it appropriately re-scheduled Miss P’s surgery in consideration of the demand on its services at that time.
36. We are sorry to hear how Miss P continued to experience pain throughout this time. We hope we have been able to explain why we do not consider anything went wrong here.
Surgery
37. Mrs P complains her daughter’s surgery was unsuccessful because while her daughter experienced some pain before this, she was able to walk independently. She says that since the surgery, her daughter is unable to walk on her own and her pain has increased.
38. The records show an orthopaedic surgeon discussed the benefits of calf lengthening and femoral rotation surgery with Mrs P and her daughter on 13 March 2020. The surgeon explained they considered this could help improve the position of Miss P’s feet and with her gait and mobility.
39. The clinical study on ‘superior functional outcome after femoral derotation osteotomy’ says femoral derotation surgery ‘is seen as the gold standard treatment in children with cerebral palsy and internal rotation gait’. In March 2020, Miss P’s surgeon noted she had a ‘notable increase in internal rotation of her right femur’.
40. The clinical study on the ‘outcomes of orthopaedic surgery with and without an external femoral derotational osteotomy in children with cerebral palsy’ concluded that this type of surgery, ‘where indicated, improved outcomes’, specifically in gait.
41. Our paediatric surgeon adviser has said in consideration of Miss P’s situation, these clinical studies support the surgery was a good choice for her.
42. In terms of the surgery, our paediatric surgeon adviser has said the operative notes support the surgeon accomplished the purpose of achieving a neutral ankle position in surgery. A second aim was to realign the lower leg, and the operative notes and subsequent clinic letters support the surgeon also achieved this. The notes reference achieving 30-degrees of external rotation.
43. In terms of measuring the success of the surgery, our paediatric surgeon adviser has explained that clinical studies about the outcomes of this type of surgery on children are highly individual. There are also differences in how clinicians measure the position of the femur, and what is considered as normal. This means it is difficult to compare the outcome of Miss P’s case against clinical studies.
44. On review of the intention of the surgery, the operative notes and the clinic reviews following the procedure, our paediatric surgeon adviser has said the records support the surgeon achieved the purpose of Miss P’s surgery. Our adviser has said they do not consider that any decline in her function following surgery was due to anything going wrong in the procedure.
45. Following review of the records, the advice we have received and the clinical studies referenced above, we find the surgical team at MTWT provided appropriate treatment and carried out Miss P’s surgery as planned. We have not seen indication this was unsuccessful in achieving its objective. We hope our explanation for how we have reached this decision brings some reassurance to Mrs P.
Post-operative care
46. Mrs P complains clinicians did not give them wound care advice following Miss P’s procedure. She says she had to seek help by talking to other medically trained people for advice.
47. The GMC’s Good Medical Practice says, ‘[doctors] must be sensitive and responsive [to those close to the patient] in giving them information and support’.
48. The records do not document clinicians specifically telling Miss P’s parents how to care for her wound. In its complaint response, MTWT said this was because the hospital was managing Miss P’s wounds. It also said its clinical nurse specialist stayed in touch with the family and apologised if they did not know they could ask them for advice.
49. Miss P was discharged three days after surgery. The nursing notes say her skin was clean and dry. She was due to be seen again for surgical review after two weeks. On 27 May, Miss P attended hospital for a change of cast and the surgeon checked and dressed her wounds. The surgeon saw her again four weeks later for review.
50. Our paediatric surgeon adviser has said there are references in the records to conversations about Miss P’s recovery, but it is not clear from the notes what clinicians said about her wound care. Our adviser has commented that as the wound was clean and dry on discharge, the risk of any further problems was unlikely. The surgeon’s plan to review Miss P and how her wound was healing two weeks after surgery was satisfactory.
51. In terms of the communication with Mrs P, the records do not document in detail the conversations that took place and so we do not know exactly what the team told her and her husband. We understand however, that Mrs P does not consider she was given the information she needed.
52. Following careful consideration, we do not consider there is sufficient evidence for us to be able to say the standard of communication from the surgical team regarding Miss P’s wound care falls so far below the GMC standards quoted above, that this was a failing. While we have not found failings here, we can see MTWT has acknowledged Mrs P’s concern and has apologised for this.
53. Mrs P complains the surgeon said they would give Miss P an orthotic boot four weeks after surgery so she could start weight-bearing and building strength in her leg. Miss P did not receive the boot until 4 August.
54. The record of Miss P’s pre-operative assessment from 30 April 2021 says the surgeon anticipated Miss P may be non-weight bearing for ‘at least 2 to 4 weeks’, and ‘potentially up to 6 weeks’. She would be in plaster during that time.
55. We have not seen reference to a plan to give Miss P a boot to wear four weeks after her surgery. The records show Miss P had her plaster cast removed on 22 June. The surgeon assessed her and decided she should be fitted for a temporary splint for night time and have an ankle-foot orthotic (a brace).
56. Our paediatric surgeon adviser has said the use of an ankle-foot orthotic following the removal of the plaster was a good choice. They have commented the issue here appears to be around communication with the family and what to expect.
57. We are sorry Mrs P was concerned her daughter was not given a boot to wear four weeks after her surgery, we understand this caused her concern. We cannot see a plan in the records for the surgeon intending to arrange this.
58. The notes do not detail exactly what the surgical team told Mrs P and her husband to expect regarding Miss P’s follow-up care. Following careful consideration however, we have not seen evidence to support the level of communication did not meet with the GMC guidance quoted above. We have therefore not seen failings in this part of the complaint.
Summary
We have carefully considered Mrs P’s complaint about MTWT. Through our work, we have found MTWT provided appropriate care and treatment for Miss P. We are sorry to hear Mrs P’s serious concerns about what happened and hope we have been able to clearly explain how we have reached our decision. We do not uphold the complaint about MTWT.
KCHT
Delay in physiotherapy starting
59. Mrs P complains that following her daughter’s surgery on 17 May and discharge home on 20 May 2021, KCHT did not start Miss P’s physiotherapy until 29 June.
60. The records show MTWT informed the KCHT physiotherapy team when Miss P’s surgery was due to take place, Mrs P also had contact with a physiotherapist during this time.
61. Miss P received physiotherapy while in hospital, and on her discharge, MTWT referred her to the KCHT community physiotherapy team to continue this. MTWT told them Miss P had gentle strengthening exercises to do and she would require stretching exercises following removal of her cast.
62. Following surgery, KCHT has told us it immediately assigned Miss P to its Level 5 Care Pathway. This Care Pathway says that within three working days of accepting the referral, a member of its therapy team will contact the referrer and the parent to discuss the anticipated actions and interventions the team will provide. It says an initial therapy assessment ‘will be offered within 48 hours of the child/ young person being discharged home’.
63. On 18 May, a KCHT physiotherapist contacted Mrs P to see how Miss P was recovering and offered to visit on 25 May to check how the transfer home had gone. Mrs P agreed to this date. This appointment was five days after Miss P’s discharge. This does not meet the 48 hour timescale set out in the Level 5 Care Pathway.
64. The Care Pathway does not refer to the timescale for an assessment in working days. We note this because we recognise Miss P left hospital on Thursday 20 May, and so some of the following days fall over the weekend. However, even if we were to discount the weekend, the appointment was offered three working days following discharge. This still misses the 48 hour timescale, we therefore find this a failing.
65. The records show the physiotherapist attended Miss P’s home on 25 May but Miss P was not there due to being at a hospital appointment. Mrs P said they had forgotten about this arrangement due to Miss P’s high care needs at that time. The team re-arranged the appointment for 2 June.
66. In terms of what happened on 25 May, we do not consider anything went wrong in the actions of the therapy team because they intended to assess Miss P on this date but were unable to. We also understand Mrs P and her family had a lot to manage at this time.
67. On 27 May, Miss P attended hospital to have a stretching cast put on her leg, this is a cast that stretches the muscles, ligaments and tendons to reduce tightness. The orthopaedic discharge notes say Miss P should begin to weight-bear (put weight on her affected leg) in two weeks time.
68. The records from KCHT say they received Miss P’s hospital records on 27 May and passed these to Miss P’s physiotherapist.
69. The re-scheduled physiotherapy appointment took place on 2 June. The notes say the physiotherapist provided advice on stretching and mobilising. There is no reference to checking the strengthening exercises Miss P had been shown in hospital, or to an assessment of Miss P’s needs in preparation for her starting therapy.
70. The therapy team planned to follow-up with Miss P in four weeks time and her block of therapy would start once her plaster had been removed.
71. The HCPC Standards of Proficiency for physiotherapists says physiotherapists must ‘be able to contribute effectively to work undertaken as part of a multi-disciplinary team’, and where appropriate, work in partnership with ‘other professionals, support staff and others’.
72. There is no reference in the notes from 2 June to the hospital’s instructions that Miss P should start to weight-bear in two weeks time. Instead, Miss P had her first physiotherapy session on the Level 5 Care Pathway on 29 June. Our physiotherapy adviser has commented Miss P’s therapy to start weight bearing should have happened in-line with the hospital’s instructions.
73. KCHT has told us it considers its therapy team liaised with the orthopaedic team to make sure Miss P’s physiotherapy was appropriate. In-line with MTWT’s plan for Miss P and the HCPC guidance quoted above, we consider the team at KCHT should have planned to start carrying out weight-bearing exercises with Miss P from 10 June. This did not happen and we consider this was a failing.
74. As set out above, we find failing in how quickly the physiotherapy team saw and assessed Miss P following her discharge home, and with when her therapy started. We have considered the impact linked to these failings further on in our report.
Lack of goal focussed therapy programme
75. Mrs P complains the physiotherapy team did not put a goal focussed therapy programme in place to monitor Miss P’s recovery and progress.
76. KCHT’s Level 5 therapy pathway says following assessment, the therapist will agree with the child/ young person and their family where appropriate: • Therapy targets and timescales (My Plan) • Appointment dates and staff to be present • A report/therapy plan will be completed and distributed.
77. NICE guidelines for managing spasticity say that following orthopaedic treatment, clinicians should ‘provide an adapted physical therapy programme as an essential component of management’.
78. The HCPC Standards of Proficiency say physiotherapists must, ‘understand the need to engage service users and carers in planning and evaluating diagnostics and therapeutic interventions to meet their needs and goals’. The standards also say physiotherapists should ‘evaluate care plans or intervention plans using recognised and appropriate outcome measures’ in partnership with service users, and revise plans where necessary.
79. When the physiotherapist attended for Miss P’s first session on 29 June, a program they had planned to go through with Miss P had to be changed. Mrs P has said this is because Miss P had not progressed as planned. A further session took place on 7 July, later the same day, Miss P had a fall at home and sprained her ankle.
80. On 9 July, the physiotherapist shared a copy of a physiotherapy program with Miss P’s parents. Shortly after this, the physiotherapist contacted the orthopaedic surgeon at MTWT to advise Miss P was reluctant to weight bear following her fall, and she was in pain. The physiotherapist asked for advice on how she could further support Miss P.
81. The orthopaedic surgeon shared the key themes needed in Miss P’s rehabilitation. These included strengthening, maintaining the length of her Achilles tendon and mobilising with encouragement to put her foot down as much as possible.
82. KCHT has acknowledged the contact with the orthopaedic surgeon did not happen until after Miss P’s surgery and it has apologised for this.
83. At an appointment on 20 July, Miss P’s father explained to the KCHT physiotherapist a private physiotherapist would now also be working with his daughter. They agreed the private physiotherapist would work on Miss P’s exercises, while the KCHT team would ‘focus on mobility’.
84. Our physiotherapy adviser has commented the records from KCHT do not contain a document called ‘My Plan’ for Miss P. The physiotherapy program the physiotherapist shared with the family on 9 July sets out some exercises but there is no reference to the purpose of these beyond general strengthening. There is also no reference to agreed therapy targets and timescales.
85. We also cannot see evidence the program was updated following the recommendations shared by the orthopaedic surgeon. Our physiotherapy adviser has said there is no evidence of a goal based therapy program being taught to the family, or of the team monitoring Miss P’s progress against this.
86. We acknowledge that from 20 July, Miss P started receiving private physiotherapy and this meant the KCHT team focussed on her mobility. This was however, three weeks in to the Care Pathway. We would still expect to see a plan (‘My Plan’) in the records, in-line with KCHT’s guidance. KCHT has told us it agrees there should have been more detail around how it planned to develop Miss P’s mobility.
87. On review of the evidence, we do not consider KCHT gave Miss P and her family a goal based physiotherapy program to follow. We have not seen evidence the exercises MTWT provided were followed-up on, or that her progress was checked. We do not consider this is in-line with the KCHT’s Care Pathway, or with the HCPC standards referred to above. For this reason, we find failing in this part of the complaint. We have considered the impact stemming from this below.
Provision of physiotherapy
88. Mrs P complains KCHT provided little therapy to her daughter between May and August and no sessions between September and December 2021. She further complains in September, the therapy team downgraded her daughter’s care pathway from level 5 to level 3.
89. KCHT’s Level 5 Care Pathway says there will be ‘a maximum of two sessions of intervention per week for the first four weeks only’, and, ‘during week 4 the therapy package of care will be reviewed and the future plan of action agreed’.
90. We have set out above that we consider the therapy team delayed assessing Miss P following her discharge home on 20 May, and the team should have started her on weight-bearing exercises from 10 June.
91. KCHT started Miss P’s physiotherapy on the Level 5 Care Pathway from 29 June. Five appointments took place over the next four weeks. We can see Miss P’s family cancelled two appointments at the end of July and in mid-August due to her attendance at summer school, and holidays. A final appointment in the Level 5 block of therapy took place on 31 August. We consider the number of sessions provided meets the Care Pathway.
92. In-line with the Level 5 Care Pathway, Miss P’s therapy package was due to be reviewed in week four of her starting therapy, with a future plan agreed for her care. The physiotherapist noted at the end of July the final session was due, but as noted above, this did not take place until the end of August.
93. There is no reference in the notes from 31 August of the physiotherapist discussing the care package with Miss P and her family or agreeing a future plan of action.
94. On 22 September, an appointment took place with the KCHT physiotherapist and a physiotherapist at Miss P’s school. This was to plan the transition to Miss P having physiotherapy at school. In the notes, the KCHT physiotherapist documents they gave Mrs P a copy of the Level 3 Care Pathway and explained what this would provide. At this point, Mrs P became very upset.
95. Our physiotherapy adviser has said there is no evidence the plan for Miss P’s care was discussed with her or her family once she completed the Level 5 Pathway. It appears the therapy team instead presented Mrs P with the information they had moved Miss P to the Level 3 Pathway rather than discussing and agreeing this at the end of the Level 5 Pathway.
96. In terms of the support provided on the Level 3 Care Pathway, it says physiotherapists should first assess the child/ young person to agree therapy targets, therapy activities, the next steps and a timeline, and the therapy team should share a report/ plan with the family.
97. Following this assessment, the therapy team can offer a range of next steps. This can include a block of intervention of four to six sessions, with up to three blocks per year.
98. We can see the therapy team offered Miss P a physiotherapy appointment on 27 October but her parents were unable to take her. The team then made an appointment for 11 November but Miss P did not attend because her parents said they were unaware of it.
99. Miss P was then due to be assessed for an Education, Health and Care Plan on 24 November which involved the physiotherapy team who planned to also review her at this appointment, but she did not attend. No appointments took place in December and the notes suggest the team planned to engage with the family to discuss next steps. KCHT has told us it became difficult for them to see Miss P. From the records, we can see KCHT tried to co-ordinate with Miss P’s family in October and November to arrange suitable appointments.
100. We can see from the correspondence between Miss P’s parents and KCHT that by September, her parents had become very unhappy with the level of support for Miss P. They had engaged a private physiotherapist for her and complained to KCHT in October. They did not agree with the Level 3 Care Pathway the team had put Miss P on, and felt she needed more regular physiotherapy.
101. We are sorry to hear of Mrs P’s frustration and unhappiness with the care provided to her daughter. On review of KCHT’s actions from September 2021, we can see it arranged appointments but Miss P was not brought to them. We consider KCHT made reasonable attempts to try to see Miss P during this time.
102. In terms of a plan for Miss P’s therapy once she had moved to the Level 3 Care Pathway, we can see the KCHT physiotherapist discussed this with her and Mrs P at her appointment on 22 September. We have not however seen evidence of an updated ‘My Plan’ or that a report/ therapy plan was shared with the family.
103. In summary, we have not seen concern with the number of sessions provided from June to August on the Level 5 Pathway, or with the sessions offered as part of the Level 3 Pathway from September 2021. However, the team did not discuss or agree the transition for Miss P to move to Level 3 with her and her parents as they should have. We have also not seen evidence a plan or report was shared with Miss P and her family once she was on the Level 3 Pathway. We do not consider these actions meet the KCHT Care Pathway guidelines and find these to be failings.
104. Mrs P has told us how she became increasingly concerned her daughter was not receiving the support she needed, and this was impacting her recovery. We have considered the impact stemming from what happened here below.
Impact
105. We have found there was delay in KCHT assessing Miss P following her discharge and delay in it starting her physiotherapy, specifically, weight-bearing exercises as instructed by the hospital. We have also seen it did not put a goal focussed therapy plan in place or monitor Miss P’s progress. The team moved Miss P to a lower Care Pathway without discussion and agreement with her and her parents. We consider KCHT has not met its own Care Plan guidelines, or the NICE and HCPC national guidelines we have referred to above.
106. We find failing in these parts of the complaint. We have carefully considered the impact linked to what happened.
107. In bringing her complaint to us in May 2022, Mrs P has told us her daughter was still unable to walk as she could before surgery. She developed Achilles tendonitis which occurs when the tendon at the back of the heel becomes swollen and painful. Mrs P says her daughter has been unable to live the life she wants and this has had a huge psychological impact on her.
108. Mrs P has told us about how difficult she has found managing throughout this time, she has suffered distress and frustration and has had to fight to get her daughter the care she needed. We are sorry to hear of the significant upset and worry she has told us about.
109. To understand the impact of the lack of appropriate physiotherapy support provided to Miss P, we have reviewed relevant clinical studies to understand the role of physiotherapy in recovery from the type of surgery Miss P had.
110. The study ‘multilevel orthopaedic surgery in children with spastic cerebral palsy’ found the success of surgery would depend on a number of factors, including ‘an early rehabilitation program’. To note, this study was published in August 2021 which is during the events in question. We consider this study relevant for us to refer to because it is a review of the existing literature already published on this subject and therefore summarises existing and accepted practise.
111. The clinical study ‘the orthopaedic aspect of spastic cerebral palsy’ concludes a key component for successful surgery is a ‘carefully planned, supervised strengthening physiotherapy rehabilitation program, with specific realistic goals for the child and family’.
112. Our physiotherapy adviser has reviewed the orthopaedic records from MTWT and has commented the expectation of the surgical team was that the surgery would help improve Miss P’s gait and mobility. A letter from a surgical review appointment Miss P attended in April 2022 refers to her struggling to return to her pre-surgical mobility and having ‘significant deterioration in her gait’. The surgeon requested further gait analysis because Miss P had not improved as expected.
113. We recognise Miss P had surgery on both her calf and thigh, and this type of surgery takes time to recover from. The orthopaedic team had predicted it may take a year for her to start showing improvements. However, on review of the clinical notes nearly a year later, we can see the orthopaedic team had concern about her recovery.
114. The records show correspondence from the KCHT therapy team to Miss P’s surgeon in July 2021. This says Miss P had been hesitant to put weight on her foot and was suffering pain. Following her fall at home, she was experiencing more pain and was even more reluctant to weight bear.
115. In August 2021, Miss P’s surgeon reviewed her and noted Mrs P’s concerns about the lack of physiotherapy her daughter had received. The surgeon noted Miss P needed to work on strengthening her leg and weight bearing. We recognise that by this time, Miss P was receiving private physiotherapy which was focussing on these exercises. KCHT has however agreed it could have liaised better with this service to help provide a better outcome for Miss P.
116. In September 2021, the MTWT orthotics team emailed the therapy team and expressed concern about Miss P’s mobility and weight bearing ability. The physiotherapy team said Miss P had not been keen to mobilise and so her outcome may not be as successful as anticipated.
117. Before surgery, Miss P was able to walk with the use of a walking aid. Our physiotherapy adviser has said Miss P should have still been able to do this following surgery. A physiotherapy assessment from June 2023 documents Miss P was now able to mobilise using a walker as support.
118. In terms of how the lack of early and structured, goal focussed physiotherapy affected Miss P’s recovery, our physiotherapy adviser has said Miss P was supposed to start weight-bearing exercises from 10 June, this did not happen and this would have made a difference to her outcome. If she had started weight-bearing sooner, it is likely she would have progressed quicker.
119. We recognise Miss P may still have been hesitant to try these exercises, but we consider the delay was a missed opportunity to start encouraging her to do these, and for her to have goals in place her parents could encourage her to meet.
120. In terms of Miss P developing Achilles tendonitis, our paediatric surgeon adviser has said this is a possible, even likely complication of the procedure. Our physiotherapy adviser has agreed this was not a surprising complication, however, physiotherapy can do a lot to mitigate against this. For example, with strengthening and training exercises.
121. Our physiotherapy adviser has concluded that with appropriate physiotherapy, it is likely that Miss P’s strength and mobility would have been better following surgery. It is not possible to say to what extent however.
122. We recognise KCHT’s comments that Miss P was not available for all the appointments offered, largely from September 2021 onwards. We also acknowledge a private physiotherapist was engaged in Miss P’s care from 20 July and this changed the focus of the care the team from KCHT would provide.
123. We also recognise what Mrs P has told us, that by September 2021, she and her daughter had become very unhappy with the care being provided and they had lost trust in the service. We consider that had the therapy team communicated with Miss P and her parents about what to expect next, in-line with the Care Pathway guidance, this could have mitigated this breakdown in trust.
124. We do recognise other factors may have affected Miss P’s recovery after surgery, such as her adhering to the exercises she was given, however, with reference to the clinical studies quoted in paragraphs REF _Ref166747898 \r \h 110 and 111 and the advice we have received, we consider the failings in the physiotherapy support likely impacted her recovery.
125. We are unable to say what difference appropriate physiotherapy would have made and consider this was a loss of opportunity for a better outcome. This uncertainty is an injustice to Mrs P and her daughter.
126. We are sorry to hear of Mrs P’s concerns about Miss P’s care and understand she has suffered significant distress and frustration trying to get her daughter the care she needed.
127. We have not found failings in all parts of this complaint and have not been able to link the full impact claimed, and so we partly uphold this complaint. We have set out our recommendations below.