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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

P-002710 · Statement · Decision date: 26 June 2024 · View Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust scorecard
Complaint (AI summary)
Ms E complained that during a hip injection, staff proceeded despite her pain and insufficient anaesthetic, and didn't consider her medical history, causing significant distress and hip damage.
Outcome (AI summary)
Closed. No indication staff acted outside guidance for anaesthetic. It was not possible to determine if the doctor should have continued the procedure due to pain.

Full decision details

The Complaint

5. Ms E complains about her experiences with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (the Trust) when she attended an appointment for a diagnostic injection into her right hip on 17 December 2021. She complains:

• the local anaesthetic had not numbed her hip and she was given no option for more anaesthetic or a longer waiting period before the injection was carried out • the staff continued with the procedure despite her showing clear signs of pain • the Trust did not read or consider her relevant medical records which would show she experiences arthritis and scoliosis and instead went ahead with the procedure.

6. Ms E says as a result of these experiences, she:

• experienced significant distress and upset during and after the procedure • has experienced damage to her right hip. She explained this has now been replaced but the initial shock from the injection vibrated through to her back which is now worse than it was before • now has pain she did not have before the injection, she is unable to sit on or put weight on her left side and is unable to do mobility and strengthening exercises she was previously doing before the incident.

7. By bringing her complaint to PHSO, Ms E states she wishes for:

• service improvements to be put in place so the future patients do not have the same experiences • financial compensation. Ms Estates she hopes to receive financial remedy within level 5 of PHSO’s severity of injustice scale.

Background

8. On 17 December 2021, Ms E attended an appointment for a diagnostic injection into her right hip at the Trust. She was told she would have a camera inserted into her hip so that a liquid could be inserted and injected through a tube into her hip. She was advised this was the first procedure to determine whether it was suitable for her to have a hip operation or not.

9. The Trust has stated in its complaint response letter dated 29 April 2022 that the procedure Ms E received was an injection of local anaesthetic into the hip joint under radiographic control or guidance. It explained the procedure requires the use of an Xray machine, fluoroscopy (a medical procedure that makes real-time video movements inside a part of the body by passing X-rays through the body over a period of time) to guide the needle to enter the hip joint. Once the correct location of the needle is confirmed, local anaesthetic is injected into the joint.

10. The Trust explained the purpose of the procedure is to see whether following the treatment the pain persists or not. The outcome then indicates whether the hip joint is the source of pain or whether other sources of pain need to be considered.

11. It stated the procedure was explained to Ms E to ensure she understood the aim of the procedure and says there was no mention of any camera or the use of keyhole surgery as this is not part of the procedure.

12. Ms E states the local anaesthetic had not numbed her and she was not free from pain. When she was first injected, due to the pain, Ms E let out a loud scream. She states the consultant did not allow more time for the anaesthetic to work or give another dose but instead proceeded with another injection which again caused her to scream in pain.

13. Ms E states she squeezed the hand of a member of staff so hard due to the pain she is not sure if she caused injury to them. She also advises the member of staff who was holding the camera in front of her showed signs she was not impressed about what was happening.

14. On 22 December 2021, Ms E raised a complaint with the Trust. She also notified her local MP who also logged the complaint with the Trust.

15. In May 2022, Ms E was told by the Trust the complaint report had been finalised and was waiting to be signed by two clinicians before being shared.

16. On 3 February 2023, Ms E brought her complaint to PHSO. She stated she was yet to receive a formal response to her complaint from the Trust.

17. On 9 February, Ms E chased the Trust again for a response via email.

18. In March 2023, PHSO sent an enquiry and second intervention letter to the Trust.

19. On 12 April 2023, the Trust responded to Ms E to advise it sent a response to her complaint to her MP on 29 April 2022. Ms E states this was never shared with her by her MP.

20. In September 2023, PHSO called the Trust asking for a final response to outstanding answers and queries and provided further time but did not receive a reply.

21. Ms E confirmed she had a hip replacement procedure done at Thornbury Hospital around three months after the incident complained about.

Findings

Ms E says the local anaesthetic had not numbed her hip and she was given no option for more anaesthetic or a longer waiting period before the procedure began.

25. We considered with our adviser what guidance was in place to state the level of anaesthetic should be given before the diagnostic hip injection procedure and if this would help to determine whether an appropriate amount was given by the Trust.

26. Our adviser explained that to their knowledge, there are no specific guidelines regarding hip injections. They advised generally, local anaesthetic is given to numb the skin and the soft tissues around the hip joint but this does not provide anaesthesia up to the hip joint capsule and some deeper tissues.

27. NHS guidance into local anaesthesia states local anaesthetics are generally very safe and serious problems are rare. It states patients may have some discomfort when the injection is given and possibly some minor bruising, bleeding or soreness where the injection was given. The Trust’s complaint response letter dated 29 April 2022 confirms this by explaining although the local anaesthetic helps to reduce the discomfort felt by the patient when the canula (needle) is inserted, it does not, unfortunately, reduce the discomfort felt when injecting into the joint.

28. The advice provided to us further explained this by saying the injection of local anaesthetic can cause some discomfort to the patient when the needle enters the deeper tissues and hip joint capsule. Our adviser re-iterated, this should be explained fully to the patient before the procedure. The Trust’s complaint response letter states the procedure was explained to the patient a few months prior and a consent form was signed by Ms E. We have, however, not seen sight of this as the Trust explained it could not be found prior to the procedure on 17 December 2021.

29. A review of Ms E’s relevant medical record shows that 10ml of 1% lidocaine (local anaesthetic) was injected into the site before the main injection. Our adviser confirmed this is an appropriate level of anaesthetic which would be used in most cases.

30. Based on the advice we have received and the available guidance, we can see the Trust acted as it should have in the level of anaesthetic it provided. We have therefore not identified any failings regarding this element of Ms E’s complaint.

31. We appreciate this decision will not be the one that Miss E hoped for and hope that the above explains how we have reached our decision. In doing so, we do not wish to downplay the physical pain and distress Ms E experienced.

Ms E says the staff continued with the procedure despite her showing clear signs of pain.

32. Part of Ms E’s complaint is that the doctor continued with the procedure despite her showing clear signs of physical pain.

33. We considered whether based on the level of discomfort during the procedure, whether the Trust was correct to continue and administer another injection.

34. The advice we received explained there is no specific guidance regarding at what point a doctor should stop the procedure. Our adviser stated this would be a matter of clinical judgement and discussion with the patient as per GMC, Good Medical Practice guidelines. This states;

‘49. You must work in partnership 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 associated risks and uncertainties • the progress of their care, and your role and responsibilities in the team.’

35. The available medical records from Ms E’s procedure on 17 December 2021 do not mention her experiencing excessive pain. This has, however, been referenced in the Trust’s complaint response dated 29 April 2022.

36. The Trust state Ms E had attended the clinic some months earlier and met with a consultant orthopaedic hip surgeon. It was during this meeting that it was agreed Ms E would have the procedure and the Trust state the consultant explained the procedure to her in detail. Ms E signed a consent form the same day confirming she understood the procedure and possible risks, including potential pain.

37. On the day of the procedure the Trust state its doctor again went through the details of the procedure to ensure Ms E understood what would happen and what the aim was. The Trust state its doctor checked with Ms E whether she felt a sharp scratch as the needle was inserted, however, Ms Edid not express any pain or discomfort at this point.

38. The Trust explains the local anaesthetic does not numb the hip capsule joint, this means when the needle pierces the capsule of the joint, it can become more painful. It advised some patients experience pain or discomfort which has also been confirmed by our adviser.

39. In its complaint response letter, the Trust explains its doctor recalls vividly the moment when the needle pierced the capsule of the joint, as Ms E made it clear she was experiencing pain. The response states the doctor asked Ms E three times whether she wanted him stop, but she told them to carry on. The Trust advise its senior operating department practitioner recalls Ms E replied ‘if that’s how it has to be, ok carry on’. It states the doctor continued with the procedure and pierced the joint capsule which was again painful. The Trust also recognises other staff within the theatre asked if more anaesthetic could be given. The doctor explained this would not reach the joint capsule and would still be painful. This is supported by the above advice we received which confirms an appropriate amount of anaesthetic was given. Our adviser also explained, should Ms E not have been able to continue with the procedure, the options would be for this to be abandoned and rescheduled under local anaesthetic or sedation.

40. We are aware Ms E’s version of events are very different. She states she experienced excruciating pain as the procedure began. She advises she squeezed one of the staff members hands and the doctor paused and walked away from her. They then continued and Ms E explains she again screamed in pain.

41. Ms E states she can confirm that the doctor did not seek her verbal consent to continue with the procedure. She also advises she did not ask for the procedure to carry on and that she was not asked by the doctor once if she wished for the procedure to stop.

42. Section 3.10 of PHSO’s service model guidance states the following,

‘There will be occasions when we decide that there are other reasons why we should not investigate a complaint made to us. These include:

• that an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.’

43. In this instance, it would not be proportionate for us to carry out an investigation into Ms E’s complaint due to the lack of evidence that is available. The recollections of Ms E and the staff members at the Trust differ greatly. In the absence of any of any other evidence, we are unable to reach a balance of probabilities decision about what happened.

44. Within the Trust’s complaint response letter dated 29 April 2022, it confirms the doctor has since reflected on the incident and will ensure in future that patients are very clear about the level of pain that may be experienced during this procedure. Whilst we appreciate this does not take away the pain and distressing experience Ms E had, we hope this will provide comfort to her that future patients should be given a clear and detailed explanation about the potential levels of pain that may be experienced.

45. We also considered whether Ms E’s medical history such as her experiencing arthritis and scoliosis should have been considered before the procedure was done.

46. The advice provided to us explained there are no notes within the medical records provided to show these things were considered, however, advised this would not have any influence on this procedure or the need for the hip injection to be done under local or general anaesthetic. We have therefore not identified any failings regarding this element of Ms E’s complaint.

47. We do not wish to downplay how upsetting and distressing these events will have been for Ms E. We hope our decision regarding the events complained about does not cause any further distress as this is not our intention.

48. Whilst we appreciate the extremely distressing circumstances surrounding the complaint, we thank Ms E for taking the time to bring these issues to our attention. We hope our investigations provide her with comfort that her concerns have been investigated fully.

Our Decision

1. We have carefully considered Ms E’s complaint about Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (the Trust).

2. We have seen no indications that the staff did not act in line with the applicable guidance when administering local anaesthetic prior to Ms E’s diagnostic hip injection.

3. We are also unable to make a balance of probabilities decision about whether the doctor carrying out the procedure should have continued after Ms Ewas displaying signs of physical pain. The statement below explains the reasons for our decision.

4. We hope the following paragraphs reassure Ms E that we have considered this matter fully and carefully before reaching our decision to take no further action in relation to her complaint. We thank Ms E for bringing her complaint to us and appreciate the time she has taken to discuss with us what was a very distressing and painful experience for her.

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