21. The Trust provided Mrs R with a telephone appointment on 16 June 2021 as she was a new patient. It also provided a follow up face to face appointment on 29 July to discuss her symptoms further.
22. During this appointment the Trust offered Mrs R an epidural (an injection into the area around the spinal nerves) for her pain. On 7 September, Mrs R attended the Trust for an epidural to provide pain relief.
23. On 29 November, Mrs R saw a doctor at the Trust who organised CT scans, and X-rays and planned to review her. The doctor also wrote to the pain clinic and separately to a clinical psychologist from the pain clinic and asked for their input.
24. In early 2022, Mrs R saw the MSK team (musculoskeletal refers to conditions that affect joints, bones and muscles) for physiotherapy. Mrs R attended appointments with the MSK team every couple of months until August of that year. Mrs R’s notes say she became stronger but had no change in the pain she was experiencing, following the appointments. During the final appointment Mrs R explained she did not require further sessions and could manage herself.
25. On 7 November 2022 Mrs R attended an appointment with a spinal surgeon. She asked the spinal surgeon for an answer one way or the other about whether surgery would be an option for her. The spinal surgeon noted they would write to a different consultant spinal surgeon and a consultant anaesthetist for a second opinion on the possibility of surgery. The spinal surgeon also noted Mrs R had not seen a pain specialist or psychologist despite the spinal surgeon’s previous referrals and they would chase this.
26. Mrs R underwent a pre-operative assessment on 22 February 2023 as part of the assessment on her fitness for an operation. She attended an appointment with the pain management team on 31 March.
27. On 11 April, Mrs R saw an anaesthetist for a review. The anaesthetist then wrote to her original spinal surgeon asking for an MDT as a matter of urgency. She attended physiotherapy pain clinics from the Trust’s pain management team in March, June, July and August.
28. Miss R contacted the Trust on Mrs R’s behalf as the family had not heard anything more about the MDT in September and this formed the start of her complaint to us. The Trust said there had been an error in communication and the anaesthetist’s letter to the surgeon had not reached his secretary and the surgeon was unaware of the need to arrange an MDT.
29. On 12 October, the Trust convened an MDT and the Trust explained to Mrs R corrective surgery would not benefit her due to her bone condition and frailty. The Trust shared this decision with Mrs R and her GP. She attended an appointment on 28 October with a spinal surgeon who explained the decision. Mrs R continued to attend physiotherapy appointments through the Trust’s pain management team.
Lack of face-to-face appointment in June 2021
30. Mrs R complains the Trust offered her a telephone appointment on 16 June 2021 when this should have been face to face.
31. In reference to the initial telephone call, the Trust says it offered new patients telephone appointments due to the COVID pandemic.
32. During the phone call the doctor spoke with Mrs R and her husband. They recorded her ongoing symptoms as ‘pain down her right thigh and leg.’ They also recorded her symptoms had started in the middle of the previous year.
33. The doctor considered Mrs R’s MRI scans (magnetic resonance imaging provides images of the inside of the body) and recorded that the ‘MRI scans do show foraminal narrowing’ (narrowing of the spine), ‘and this would explain her symptoms’.
34. The doctor arranged a face to face appointment for 29 July, just under two weeks after the telephone appointment. During this appointment Mrs R provided consent for an epidural injection.
35. In November 2020, the NHS published a guide for NHS health care providers around the management of patients through remote (telephone) consultations. The guide says:
‘Using remote consultations supports with coronavirus response by:
• preventing the transmission of the disease by reducing the need for patients to travel into hospital • allowing clinicians to speak to patients who are unable to travel to hospital (for example patients in at risk groups, or due to self-isolation or travel difficulties) • allowing clinicians to carry out clinical work from home (for example staff in at risk groups, or due to self-isolation or travel difficulties) • supporting providers to meet increased demand in a particular locality.’
36. This guidance was still relevant in June 2021 as the NHS continued to implement COVID restrictions. As such we find it acted appropriately and in line with the above guidelines by providing an initial telephone consultation. We can see the doctor arranged for Mrs R to attend a face to face appointment and for the Trust to discuss epidural pain relief. We appreciate the frustration Mrs R felt at not having a face to face appointment initially. We have not found failings in this part of the complaint.
Referral for an urgent MDT in April 2023
37. Mrs R complains an anaesthetist at the Trust requested an urgent MDT in April 2023 with the spinal team, but this did not take place until 12 October following her complaint.
38. The Trust apologised and said it was sorry the MDT did not place earlier. It explained the spinal surgeon’s secretary was unaware of the request for an urgent MDT due to poor communication from the anaesthetist’s department.
39. Mrs R saw the anaesthetist in April 2023 who advised her that her condition had deteriorated, and she would need multiple operations to correct it, which she may not tolerate. During the appointment the anaesthetist also advised her that an urgent MDT was necessary. The anaesthetist said they would speak with other doctors, surgeons and physiotherapists to decide on a plan to achieve a better quality of life for Mrs R.
40. Mrs R complained to the Trust in September having not heard anything further about the MDT. Following the complaint and the Trust’s investigation, the MDT took place in October 2023 (six months after the anaesthetist requested it) and doctors explained to Mrs R corrective surgery would not be an option for her.
41. Our adviser explained, by their very nature MDT discussions take time to organise and are there to help decision making in complex cases and are therefore not clinically urgent situations. Our adviser went on to say, Mrs R’s notes do not show evidence her condition needed an urgent assessment or treatment. Therefore, the timeframe of six months is not unusual and within normal timeframes for these types of meetings.
42. We fully appreciate the MDT only took place because Mrs R and Miss R chased it. We find the Trust should have convened an MDT earlier than it did as this was its plan. It is clear there was miscommunication between departments that led to a delay in having the meeting. We find this a failing by the Trust and not in line with our ‘Principles of Good Administration’ which say:
‘Public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. They should meet their published service standards, or let customers know if they cannot.’
43. And:
‘Public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case. Where appropriate, they should deal with customers in a co-ordinated way with other providers to ensure their needs are met; and, if they are unable to help, refer them to any other sources of help.’
44. We have seen this led to a delay in the MDT taking place. We can see this caused Mrs R and her family emotional distress and anxiety as they had to chase this with the Trust and they did not know if a potential delay was going to affect Mrs R’s chances of surgery. We have found the delay in the MDT did not affect her care because ultimately the purpose of the MDT was to decide about potential surgery. The decision of the MDT was, Mrs R was unsuitable for surgery. As such, we find a delay did not affect the overall decision or Mrs R’s overall care.
45. We next considered what the Trust has already done to address the impact of this failing. The Trust has already acknowledged and apologised for this failing. It has also shared learning with the anaesthetist’s department in which the error originated through an action plan. This is in line with our ‘Principles of Remedy’ which say public bodies should take:
‘remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these’.
46. We consider the action the Trust has taken to be appropriate and that it should prevent the same error from recurring, as such we do not think there is anything further the Trust should do to put right the impact of this failing on Mrs R and her family.
Overall care and treatment between June 2021 and October 2023
47. We next considered whether the Trust provided appropriate care for Mrs R’s degenerative scoliosis during this period. Between June 2021 and October 2023, the Trust reviewed Mrs R and sent her for multiple scans. It also referred Mrs R to the MSK clinic and to the pain management service.
48. Our adviser helped us to understand there is a lack of guidance related to the treatment of degenerative scoliosis. This is because there is a lack of evidence of effective treatments. NICE’s ‘Low back pain and sciatica in over 16s: assessment and management’ covers the treatment of back pain with sciatica but does not make specific reference to degenerative scoliosis or how best to treat it.
49. Our adviser went on to explain the treatment of degenerative scoliosis is complex and controversial. There are no well-established treatments for the prevention or treatment of degenerative scoliosis. Taking this into account, we find the Trust’s treatment of Mrs R’s condition was appropriate. The Trust made appropriate referrals to the pain clinic and anaesthetist and sought second opinions regarding complex surgery in a timely manner. Following the MDT in October 2023 the Trust’s view was Mrs R was not suitable for corrective surgery. We find there is no evidence the Trust’s actions affected the decision it made regarding her qualifying for surgery.
50. We do not consider an earlier referral would have made any difference to Mrs R’s options for surgery.
51. As part of our consideration of the care provided by the Trust, we considered the length of time it took for Mrs R to receive an appointment with the pain clinic. The Trust referred her to the pain clinic in December 2021 (this included a letter to the pain clinic’s psychologist) but she did not receive an appointment until March 2023 which was 15 months later.
52. We cannot see the Trust directly addressed this issue within its complaint responses. We spoke with the Trust and it acknowledged there were errors in the referral process. Specifically, the Trust told us the way in which the spinal surgeon made the referral was incorrect and this was as a result of a discontinued pilot project. The surgeon used a referral process which would have been relevant during the pilot but this had finished and so it was no longer appropriate. This meant the psychologist in the pain clinic did not receive the referral. We find this a failing by the Trust and not in line with our ‘Principles of Good Administration’ which say:
‘Public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot. They should meet their published service standards, or let customers know if they cannot.’
53. The Trust did not do this. During our investigation, the Trust also clarified the average waiting time for patients to see the psychologist in the pain clinic during 2021-2023 was around 60 weeks.
54. This response has not addressed whether the delay in the referral meant a delay in Mrs R seeing a physiotherapist rather than a psychologist. We have not seen evidence Mrs R has seen a psychologist from the pain clinic or that she needed to see one following her assessment at the pain clinic. As such we have considered whether there was a further impact.
55. Mrs R’s spinal surgeon picked up on the lack of contact from the pain clinic on 7 November 2022 during a review and said they would chase this. From the Trust’s response it is unclear whether the original referral to the pain team reached them. We consider this unlikely as when the spinal surgeon chased the referral in November 2022, the team sent Mrs R an appointment letter in March the following year. This was four months after the spinal surgeon chased the referral. We can therefore say it appears there was a four month wait. Had the Trust’s referral been successful in December 2021, it is reasonable to say the physiotherapist would have seen her in approximately April 2022. Therefore, we consider there was a delay of eleven months in Mrs R seeing the physiotherapist in the pain management team. There is a lack of evidence in Mrs R’s medical notes regarding the effect of the physiotherapy she later received on her pain levels. It is clear the exercises she did strengthen her but that her medication was controlling her pain well. As such, we find the delay in referral to the pain management team meant an 11 month delay in Mrs R receiving strengthening exercises which helped her go about daily activities.
56. We have therefore found failings in this part of the complaint and go on to make recommendations later in our report.
Osteoporosis
57. Mrs R also says the Trust did not provide treatment for osteoporosis. We consider it is not the role of a spinal surgical service to provide treatment for osteoporosis. This management of this is usually provided by GPs or metabolic bone disease (health disorders because of problems with bone strength) teams. Our adviser helped us to understand, it would not have been appropriate for a surgical service to start a potentially long term treatment for Mrs R that might not be compatible with other treatments started by her GP. This could have potentially negative health impacts for Mrs R. As such, we have not found failings in this part of the complaint.
58. We have not found failings in the Trust providing an initial telephone consultation or in its overall care and treatment of Mrs R between June 2021 and October 2023. Additionally, we have not found failings in the Trust not treating Mrs R’s osteoporosis. We have decided that we will not uphold these parts of the complaint.
59. We also considered the Trust’s urgent MDT referral in April 2023 and its referral to the pain team in December 2021. We have found failings in the Trust’s management of these referrals. We have found this led to emotional distress and worry for Mrs R and her family. Regarding the MDT referral, the Trust has already addressed this, and we have decided there is nothing further it should do. Regarding the pain management team referral, we find the Trust has not addressed the impact of this. As such, we have decided we will partly uphold this part of the complaint.