Lewisham and Greenwich NHS Trust

5. Mrs R, represented by her husband and advocate, complains about aspects of the care and treatment she received following hip replacement surgery on 3 September 2021 at the Trust where she was an in-patient for nine weeks.

6. Specifically, she complains the Trust: • did not consider her difficulties with memory when explaining the risks of the surgery and post-op healing. She says the Trust failed to communicate updates with her next of kin • did not X-ray her post-op and • failed to diagnose the displaced femur until 6 September 2021

7. Mrs R says the delay in sending her for a scan and identifying the displaced femur resulted in prolonged pain before the revision surgery. She says this has had a longterm effect on her mobility. She says she has since been told there is ‘too much space around the ball socket’ and remains very restricted in her mobility.

8. She says the poor care and communication caused distress for her and her husband.

9. Mrs R seeks an apology, service improvements and financial remedy.

10. On Monday 3 September 202, Mrs R underwent a total hip replacement.

11. On Friday 6 September 2021 Mrs R was taken for an X-ray, and it was discovered her hip was dislocated. Mrs R was returned to theatre for realignment.

16. Mrs R complains the Trust did not consider her difficulties with memory when explaining the risks of the surgery and post-op healing. She says the Trust failed to communicate updates with her next of kin.

17. In its response on 12 August 2022, the Trust said Mrs R was first seen in the Orthopaedic clinic on 13 May 2019 where a member of staff took her through the consent form for the surgery. This included explaining the risks of the procedure such as dislocation.

18. The Trust said on 19 September 2019, Mrs R was seen in a pre-assessment. She was seen by the physiotherapy team on 8 October 2019. The Trust noted Mrs R total hip surgery was delayed due to a medical emergency which required Mrs R to undergo a total of eight operations between 2019 and 2021.

19. The Trust said Mrs R was seen again by a doctor and added to the waiting list on 26 May 2021. The Trust noted Mrs R was provided with information from EIDO Healthcare which is an organisation that provides health professionals with the resources to support informed consent. Specifically, the Trust said it provided Mrs R with information from OS01 which is a leaflet for the code of hip replacement.

20. The Trust said Mrs R attended a further pre-assessment appointment on 1 July 2021 before her procedure in September 2021.

21. The Trust said dislocation is listed as a complication in: • the EIDO leaflet • 13 May 2019 consent forms and • 3 September 2021 consent form.

22. The Trust said at the time of initial consultation in 2019 there was no evidence of dementia or memory loss. The Trust said Mrs R was found to have capacity to make decisions regarding her healthcare at all appointments prior to her surgery. The Trust explained Mrs R had been given information verbally and in writing through the leaflets provided.

23. The Trust explained it did not speak with MRs R’s husband, Mr R, until 8 September 2021. Where patients have capacity it is not common practice to speak with relatives unless specifically asked to by a patient.

24. Mrs R, with the support of her advocate, explained she was experiencing significant memory loss which was being investigated for dementia. The advocate raised the concern whether Mrs R had been given all the information about the risks of her surgery and how the information had been provided when obtaining her consent.

25. On 28 March 2024, we contacted the Trust to request additional clinic letters from 13 May 2019 and 26 May 2021. It said it was unable to locate the consent form filled out in clinic from appointment date of 13 May 2019. It explained Mrs R would have received a copy at the time. The Trust noted there was an accompanying clinic letter which explained Mrs R was taken through consent for her operation. Due to the time that has lapsed since the clinic appointments in 2019 Mr and Mrs R have been unable to locate the copies of the leaflet provided at the time.

26. The Trust was unable to provide the EIDO Healthcare leaflet issued to Mrs R in 2021. It did provide a more up-to-date version of the leaflet however, this is not applicable to the period we are considering.

27. The Trust provided consent forms for 3 September and 6 September 2021. These are the consent forms which were signed close to Mrs R’s admission to the Trust.

28. Both consents form, signed by Mrs R, details a list of ‘significant, unavoidable, and frequently occurring risks’ such as: • pain • infection • revision surgery • DVT (deep vein thrombosis), this is a blood clot in a vein, usually in the leg • fracture • wound issues

29. We recognise this is not a complete list of potential risks and consider, on a balance of probabilities, this indicates the Trust discussed risks with Mrs R prior to her appointment.

30. We understand since her total hip replacement surgery, Mrs R has since been diagnosed with dementia. We recognise this has been an exceptionally difficult time for Mrs R and her family. We appreciate they have concerns around how the Trust assessed Mrs R’s capacity and obtained fully informed consent to the operation and its risks. We understand Mrs R and her family are concerned the Trust did not provide updates to her next of kin.

31. It is not typical practice for doctors to update the family or next of kin when a patient has been assessed as having capacity. Mental capacity is assessed separately from diagnosed cognitive conditions, such as dementia, as capacity can change over time in both the short term and the long term. Cognitive impairment does not indicate a lack of capacity and there is evidence the Trust assessed Mrs R’s capacity independently prior to her surgery and during her inpatient stay post-recovery.

32. There is evidence within the records the Trust communicated with her family once the dislocation had been identified. On 9 September the Trust contacted Mr R to discuss issues. We consider the Trust did communicate with the family during Mrs R’s inpatient stay.

33. In summary, we have seen no failing in how the Trust obtained Mrs R’s consent for her elective hip surgery. As such we will not uphold this part of Mrs R’s complaint.

34. We thank Mr and Mrs R for bringing this complaint to us and we hope she will find our decision useful in confirming we have not seen any indications that something went wrong with her care.

X-ray

35. Mrs R complains on 3 September 2021 after her total hip replacement, the Trust did not X-ray her post-operation and failed to diagnose the displaced femur until 6 September 2021.

36. In its response on 12 August 2022, the Trust said Mrs R underwent her total hip replacement on 3 September 2021 and was reviewed at 9am the following day where it was noted she was ‘sore to move but was not in pain at rest’. An X-ray was requested shortly after.

37. The Trust said a physiotherapist reviewed Mrs R at 12.41pm on the same day who noted Mrs R had severe pain on moving and requested an X-ray requested was done on the same day due to the level of pain Mrs R reported.

38. In its response, the Trust noted that 4 September 2021 was a Saturday and as such the request was considered an ‘onsite urgent ward request’ because it was out of normal hours. The Trust explained an urgent ward request is completed by the ward staff, or requesting clinician, who contacts the out of hours staff to alert them of the request. The Trust said due to the ten months between incident and investigation it had not been possible to establish the reason for delay from the Radiology department.

39. The Trust went on to note a Trauma and Orthopaedic Registrar reviewed Mrs R again at 10am on 5 September 2021 and identified her leg was externally rotated (pointing outwards) and an urgent request for an X-ray was made. The Trust said a discussion between clinician and radiology department was documented and the clinician was assured an X-ray would be performed on the same day.

40. The Trust said Mrs R’s records had been accessed and there was no documentation available, and it had not been possible for the Trust to establish the root cause of delay. It suggested this could be a combination of ‘ineffective communication and/or portering resource.’ The Trust said the expectation is for the ward to escalate an urgent request to the site manager when a delay occurs out of hours.

41. The Trust said on 6 September 2021 another urgent X-ray request was made and at 12.41am. Mrs R went for an X-ray which showed anterior dislocation of the hip. The Trust explained as there was no documented episode when a dislocation was identified it could not be certain when the dislocation happened. In its response the Trust acknowledged a delay of 48 hours in providing Mrs R with an X-ray.

42. On Friday 3 September 2021 after her surgery Mrs R was asked to walk the same evening and every day after until Monday. She said she reported being in pain and unable to ‘weight bear’ as instructed. On 6 September 2021, Mrs R was taken for an X-ray, and it was found her hip was not aligned. She was returned to theatre the same day for a realignment.

43. NG157 states a patient should be encouraged to mobilise on the day and no more than 24 hours after surgery. When the Trust asked Mrs R to mobilise and weight bear postsurgery, the Trust was acting in line with NICE guidance. Our adviser explained this is done as studies indicate rehabilitation within 24 hours of surgery, including mobilisation, reduces length of hospital stays.

44. The medical records show the Trust documented discussions it had with Mrs R including the pain she reported experiencing. Our adviser noted this was an indication the Trust suspected something was wrong due to the pain being reported and the inability to weight bear. Our adviser explained the suspicion something was wrong with Mrs R could not be confirmed until an X-ray was done.

45. The BOA Good Practice sets out the expected standards of care for patients who have undergone a total hip replacement. The BOA states an X-ray should be completed before a patient is discharged from hospital. This is done as a method to document the success of an operation.

46. Our adviser explained while the BOA Good Practice does not specify when a scan should take place it is standard practice to do this as soon as possible. This is typically the same day or the day post-surgery. Our adviser noted the Trust agrees with this practice, as seen in its final response, which is for patients to have an X-ray the day after surgery.

47. In line with BOA Good Practice and NICE guidance, the Trust should have provided Mrs R with a post-operative X-ray on the same day or within 24 hours of her surgery. From the evidence we have seen, we have found the Trust did not provide Mrs R with an X-ray until 48 hours after her surgery. We have not seen any evidence which provides an explanation for this delay.

48. We consider the Trust delay in providing Mrs R an X-ray contributed towards dislocation not being identified until 6 September 2021, three days after her surgery. We consider this contributed to Mrs R’s feelings of pain, distress, and uncertainty.

49. Mrs R says the delay in the X-ray contributed to the Trust failing to diagnose the displaced femur until 6 September 2021. She explained she was in prolonged pain before the dislocation was treated. Mrs R believes this had a long-term effect on her mobility. She says she has since been told there is ‘too much space around the ball socket’ and remains very restricted in her mobility.

50. We recognise Mrs R experienced significant and prolonged pain for three days before the dislocation was identified. We understand Mrs R would have been in considerable distress and feeling uncertain about the care she was receiving. We do not underestimate how upsetting this experience was for her.

51. There is no evidence to indicate the Trust’s delay in providing an X-ray can be linked to any long-term pain or discomfort Mrs R has experienced. Our adviser explained a dislocation can be extremely painful and uncomfortable until it is realigned. We consider Mrs R’s dislocation was treated in a timely manner once identified and she continued to stay as an inpatient at the Trust for several weeks following her surgery. There is no indication in the medical records Mrs R experienced any permanent injury from the dislocation. As such we are unable to link any long-term difficulties to the X-ray delay.

52. In its responses the Trust have not acknowledged the pain and distress Mrs R experienced post-surgery. In its response on 12 August 2022, it acknowledged the delay but was unable to provide an explanation. There is no evidence the Trust has taken any action to remedy Mrs R’s complaint.

53. It is for this reason, we partly uphold Mrs R’s complaint.

1. Mrs R complains about aspects of the care and treatment she received post hip replacement surgery at Lewisham and Greenwich NHS Trust (the Trust).

2. We consider there was a three-day delay in providing Mrs R with a post-surgery X-ray which resulted in Mrs R experiencing significant pain and a delay in her dislocation being diagnosed.

3. This means we partly uphold Mrs R’s complaint. We consider the delayed X-ray caused an impact which needs to be put right. We are recommending the Trust pay Mrs R £390 in recognition of the significant pain and distress she experienced. We are also recommending the Trust put in place an action place to explain how it will do things differently to prevent reoccurrence.

4. We are not fully upholding this complaint because we think the Trust acted in line with relevant guidance when it obtained Mrs R’s consent for the hip replacement surgery.

54. In considering our recommendations, we have referred to our ‘NHS complaint standards’. Our Complaint Standards support organisations to provide a quicker, simpler and more streamlined complaint handling service. They have a strong focus on: • early resolution by empowered and well-trained people • all staff, particularly senior staff, regularly reviewing what learning can be taken from complaints • how all staff, particularly senior staff, should use this learning to improve services.

55. Our NHS Complaint Standards say where maladministration or poor service had led to an injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. An appropriate range of remedies will include an apology, an explanation and service improvements. We look to put the person affected back into a position where would have been had there not been a negative impact on them. Where this is not possible, we may suggest a financial remedy.

56. Based on the information available we have determined Mrs R experienced significant distress and pain because of the delay in X-ray. This is aligned with level two on our Severity of Injustice (SOI) scale. This is a scale which allows the Ombudsman to make consistent and transparent recommendations for financial loss that has six levels. The scale ranges from level one where we see low level injustice to six, where irreversible damage, loss of life or extremes of failure in care occur. It is available on our website.

57. A level two injustice will be considered when the injustice was more serious but only took place once. In these cases, we consider an apology is not suitable by itself.

58. As a result of her complaint Mrs R is seeking an apology, service improvements and financial remedy.

59. Mrs R reported experiencing significant pain, distress and upset for the three days until the dislocation was identified and realigned. We would place Mrs R’s complaint at Level 2 (£120 - £550) and based on previous cases of a similar nature, we consider a suitable financial remedy for Mrs R would be for the Trust to pay her £390. This is in recognition of the significant pain she experienced because of the dislocation which was not identified and treated for three days.

60. We consider Mrs R to have recovered once the dislocation was identified and treated, we can see she remained as an in-patient for nine weeks to ensure a stable recovery and safe discharge. We consider the delay in X-ray and treatment of dislocation did not have a significant lasting impact on Mrs R.

61. During our investigation we contacted the Trust to confirm what Radiology policies were in place at the time of Mrs R’s complaint and whether there had been policy changes following Mrs R’s complaint.

62. The Trust provided its Radiology Regulation Policy, this policy sets out the process for accepting and actioning referrals. The Policy explains that a referral for a ‘diagnostic medical exposure’ (an X-ray) must include sufficient medical data to be accepted, which is a legal requirement. Referrals can be made by completing a request form by hand or electronically via the iCare system. The Trust’s Radiology Regulation Policy states any request which does not meet the requirements should be deferred and for a discussion to be had with the referrer to record the relevant clinical information.

63. Based on the available medical, the Orthopaedic ward where Mrs R was an inpatient made four referrals to Radiology between 4 to 6 September, including a documented discussion on 5 September 2021 where a same day X-ray was guaranteed. We do not consider the Orthopaedic ward be responsible for the delay in providing the X-ray. There is no evidence to indicate the Orthopaedic ward made an inadequate referral to Radiology.

64. We are unable to determine why Mrs R’s X-ray was significantly delayed. We asked the Trust if there were any policies relating to how staff should manage the escalation of urgent out of hours requests. The Trust explained it did not have any policies relating to this.

65. Having taken this into consideration we have not seen evidence the Trust has done enough to put things right and provide assurance of service improvements.

66. For this reason, we recommending the Trust update its Radiology Regulation Policy to detail a process for staff to follow when there is an urgent out of hours request. We will provide the Trust with our action plan template and checklist to assist it in creating an action plan which will address the failing we have identified.

67. The action plan should include the action, who is responsible for the action, the timescale for completing the action and how it will be monitored to ensure improvement. We are suggesting the Trust do this within three months of the date of our final report.