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.