Cubital tunnel surgery
8. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indications that something has gone wrong.
9. Mr I told us the plan was for the Trust to carry out carpel tunnel surgery to help relieve symptoms of repetitive strain injury. He told us he consented to carpel tunnel surgery which he expected to come around from to find a small amount of bandaging over the wound. Instead, he says his whole arm was bandaged. He was then told he had had cubital tunnel surgery. We understand this was very upsetting for Mr I. The Trust has maintained the surgery carried out was what was intended.
10. In order to gain an understanding of what happened we considered the records and correspondence leading up to the surgery on 28 January 2022. We also asked our clinical adviser to review these records and to refer to relevant guidance.
12. Looking at Mr I’s clinical history we can Mr I was diagnosed with mild carpal tunnel syndrome at a clinic on 18 July 2018. We also note that in reference to this condition the consultant neurologist writing to Mr I’s GP commented this condition should be managed conservatively with splinting or injections but not surgery.
13. Further to this, in February 2020, the consultant neurologist noted Mr I exhibited numbness in his hands and that he had had a positive Phalen test. A Phalen test is used to diagnose carpal tunnel syndrome. The suggestion was a combination of carpal tunnel syndrome and non-specific fibromyalgia. Nerve conduction studies were to be arranged to understand further but they were cancelled by Mr I on two occasions. The neurologist then wrote to orthopaedics in May 2021 noting numbness of the fingers, left ulnar neuropathy (the entrapment of the ulnar nerve) and some incidental mild carpel tunnel syndrome.
14. We can see references to carpal tunnel in Mr I’s clinical history however no plan was agreed to complete carpel tunnel surgery as a result. We can see that at the appointment on 18 June 2021 there is a change in clinical approach. We appreciate this change in approach may have caused Mr Hijazi some confusion.. However, while we have not seen any planned carpel tunnel surgery we can see from this point cubital tunnel surgery was consistently referenced. There was a diagnosis of cubital tunnel and surgery planned to manage that.
15. The clinic letter from this appointment (although refers to 17 June we believe that has been done in error) talks about having consented Mr I during the clinic. The records also support that in the clinic on 18 June 2021 the consent process was started. This consent form also states, ‘Expires end of June 2022’ suggesting consent being valid for the next 12 months. Beneath the surgery date is a heading ‘Intended Procedure’. Next to this the form is completed by hand with L (in a circle indicating left) CABITAL TUNNEL DECOMPRESSION. Having considered this it appears that this is a spelling error, and the intended word was cubital. We base this on there being no known ‘Cabital’ surgery process and the difference in the two being one letter (A for U). It is unfortunate there is an apparent handwriting error in the circumstances of this complaint, but we do not consider this indicative of a failing. We do appreciate why the crossing out on the consent form may have raised concern, but we have seen a general plan for cubital tunnel ahead of the procedure, which was previously shared.
16. Following the 18 June 2021 appointment the Trust sent a letter to Mr I’s GP which he was copied into. This letter set out that nerve conduction studies confirmed left cubital tunnel syndrome. The letter also confirmed Mr I had been consented for cubital tunnel decompression stating Mr I had chosen to go ahead with the operation rather than a splint. Given that this letter was copied to Mr I we are satisfied he was given opportunity to read and note its content. Furthermore, it suggests accompanying conversation about the plan at the appointment. Overall, the evidence supports the plan was for cubital tunnel from this appointment and this was shared with him.
18. We also considered events on the day of the operation. Mr I signed the consent form before the operation on 28 January 2022, completing the consenting process. His signature is countersigned by a clinician. Mr I has told us he has concerns his consent form was altered but have seen a consistent approach to suggest cubital tunnel and we have not been able to say when this was altered.
19. The Day Case Discharge Summary, further to the operation, dated 28 January 2022, also shows the presenting complaint to be Cubital tunnel syndrome and the Primary/Actual Diagnosis as Cubital tunnel syndrome. Again, this supports the view that the intended operation was for cubital tunnel decompression.
20. We considered a printed form Mr Hijazi provided to us. The form shows it is from Barnsley Hospital NHS Foundation Trust and appears to be form ‘OS05’. It is headed (in print) ‘Carpel Tunnel Release’ which is crossed through and in handwriting we can see ‘CUBITAL TUNNEL RELEASE’. This form is not dated but in print it does say expires ‘end of June 2022’. We understand this document is the top sheet of an aftercare leaflet provided to patients following surgery. Mr I confirmed this was given to him when he was discharged by the Trust. We appreciate this may have also raised concerns but it seems likely it was change of use for the aftercare leaflet rather than supportive of a different procedure being done.
21. Mr I’s discharge documentation also shows the primary/actual diagnosis as Cubital Tunnel Syndrome. This document also lists the relevant investigations, operations, procedures, and findings as ‘Cubital tunnel decompression at elbow-left’.
22. We fully appreciate Mr I explained he was very distressed when he had expected a carpel tunnel operation and accordingly little by way of dressing and for it to be limited to his hand and instead he woke up to find his arm in a cast. We can see no suggestion in the records that was noted as a concern at the time. Similarly, we can see no suggestion of staff being aware of concerns in the period after the surgery, or at discharge. Similarly, at his follow up appointment on 6 February there was no mention of concerns. Instead, the focus was on his improvement in symptoms, albeit pain was noted. Again, the reference is to being a post operative surgery further to cubital tunnel.
23. The first reference we can see of his concerns was in his approach to PALS in a letter from Connect Health dated 17 May 2022. Connect Health is a pain management clinic. It also notes that Mr I had a solicitor instructed but does not say in what regard. Nevertheless, this is about four months after the operation.
24. With the above considerations in mind, we conclude that the planned surgery was a cubital tunnel procedure. Accordingly, we have no concerns that the Trust completed an inappropriate procedure. We realise that this conclusion might be upsetting for Mr I but hope our careful consideration of the facts will demonstrate that we have taken everything into account in reaching it.
Severed nerves
25. Mr I told us that as a result of his surgery on 28 January 2022 nerves for two of his fingers on his left hand were damaged. This is not disputed by the Trust who flagged up it was a highlighted risk of the procedure. Accordingly, our focus is whether that is reasonable and whether it appears the Trust appropriately communicated this. As discussed above, in preparation for the operation there were meetings with the Trust. As part of obtaining consent it is expected for risks to be shared and considered. Specifically there is an area on the consent form which focuses on this on the pre-printed form.
26. The consent form dated 18 June 2021 deal with this in the area setting out ‘serious or frequently occurring risks.’ One of the known risks is recorded as nerve injury.
27. We asked our adviser whether there was any indication of failing associated with the nerves being severed. Our adviser confirmed the possible severing of nerves/nerve injury is a known risk with this type of operation, highlighted that this is mentioned in some of the records and that the possibility of nerve damage was explained during the consent process. Having reviewed this case our adviser confirmed they could not see any failings in what was done during the procedure, and no suggestion that there had been problems during the procedure.
28. We also considered whether appropriate information was shared about the possibility of nerve damage. The relevant guidelines considered in reaching this decision were the General Medical Counsel Consent Guidelines. With reference to the guidelines (Recording decisions - decision making and consent - professional standards - GMC (gmc-uk.org)). The consent process involves not only discussing the planned procedure and what it should achieve but also any risks the procedure involves.
29. On the consent form (discussed above) dated 18 June 2021 there is a section headed ‘Serious or frequently occurring risks.’ This section is completed by hand and records (as risks) ‘Infection, bleeding and nerve injury’. This consent form is signed by Mr Hijazi on 28 January 2022.
30. Given that we can see nerve damage is a known and (by virtue of the consent signature) accepted risk with this procedure, we do not consider the nerve injury complained about by Mr I to be a failing. In the circumstances we take the view the nerve injury experienced was extremely distressing but not a failing.
31. We recognise that whether this nerve damage was a known risk or not, it will have been very difficult for Mr I to go about his day-to-day life with such an injury and we are sorry he has had to go through this. We also know the outcome of our considerations will probably be upsetting for Mr I. We hope our explanations show we have carefully considered the matters he brought to us.