Staff member that performed Mr A’s surgery
20. We are an ombudsman provided for, and funded by, the public. We need to ensure that we maintain a balance in our work. This is to ensure we use our resources to focus on those where we can achieve the most impact and support those who need our help the most.
21. Our Service Model guidance says in some circumstances we will take the decision to not consider a case where someone tells us that the injustice they have experienced has not had a significant or lasting impact on them, or the person they are representing.
22. We must be proportionate with our resources to achieve the most impact for complainants. We are therefore not currently considering cases that fall on level 1 or 2 on our severity of injustice scale.
23. We have considered the concerns raised by Mrs A and how they impacted on her and Mr A to decide if we should consider this further. We have then considered where this falls on our severity of injustice scale.
24. Mrs A said the Trust informed her that its consultant rhinologist performed the adenoidectomy. Mrs A said when she received Mr A’s medical records, she discovered it was a rhinologist fellow that completed the surgery, and not the consultant as they were told. A fellow is a qualified doctor undertaking specialised training, in this case in rhinology.
25. The Trust said the fellow in question is a trained surgeon and has previously worked as a consultant in a different specialty. The Trust explained the fellow was undertaking a two-year advanced rhinology fellowship and was in their second year of this fellowship at the time of the surgery. The Trust said the fellow is competent to undertake the surgery and is a senior member of the team.
26. PHSO’s principles of good administration says public bodies should give people information that is clear and accurate.
27. Mrs A told us following Mr A’s adenoidectomy she asked a nurse how the surgery went, and it was at this point she was informed the consultant had performed the surgery. We have reviewed the medical records and have been unable to find any reference to the nurse’s conversation reported by Mrs A. We have no reason to doubt what Mrs A has told us here.
28. Mrs A said during Mr A’s admission, the fellow informed her and Mr A the operating surgeon went too far back during the surgery and suppressed a nurse. Mrs A said the fellow lied about who had performed the surgery due it to going wrong.
29. We understand Mrs A has told us she was informed the consultant performed the surgery by the nurse and this was further supported by the discussion she had with the fellow. We think there is an indication of a failing here as Mrs A was not provided clear or accurate information regarding who performed Mr A’s surgery.
30. It appears Mrs A was incorrectly informed the consultant performed Mr A’s adenoidectomy. This is not in line with PHSO’s principles of good administration which says organisations should provide accurate information. We appreciate the nurse informing Mrs A the consultant performed the surgery could have occurred due to an unintentional human error, particularly as the fellow was also a consultant in another speciality.
31. We also think there is an indication of a failing in the discussion Mrs A had with the fellow. Mrs A said the fellow referred to the ‘operating surgeon’ going too far back during the surgery. We think the language used does not clearly explain it was the fellow that performed the procedure. This is not in line with PHSO’s principles of good administration which says information should be provided in a clear manner.
32. Given there appears to be an indication of a failing here, we will next look at the impact caused by this.
33. Mrs A said the Trust not being truthful about who performed the operation has left her and her husband feeling lied to and it was shocking for them to discover. Mrs A said this caused further distress to both her and Mr A.
34. We have considered the emotional impact claimed by Mrs A in line with our severity of injustice scale. Levels 1 and 2 deal with distress, worry, annoyance, frustration and similar emotional impacts. Our scale says this could be an injustice that only took place once, or for a short duration. It says this would not impact on the affected person’s day to day functioning, or their ability to live a normal life, for a period of up to six months.
35. We understand Mrs A’s concerns and the distress this caused to her and Mr A. Level 2 on our scale says we would reasonably expect any impact to diminish completely in the fullness of time and it is for shorter periods of more serious distress. We do not think we could link the emotional impact on Mr and Mrs A to a period longer than six months, and this complaint would therefore fall on the lower levels of our scale.
36. We recognise Mr and Mrs A experienced shock and distress when they learnt who had undertaken the operation. In line with our service model guidance, we do not think it would be proportionate to consider this part of the complaint further. We will therefore not take any further action on this point.
Adenoidectomy Surgery on 6 July 2022
37. 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.
38. Mrs A said the rhinologist fellow, who performed the surgery, informed them they had gone too far back during Mr A’s surgery. Mrs A said they informed her and her husband they had suppressed a nerve at the back of Mr A’s neck.
39. Mrs A said this caused Mr A to develop a blood clot in his neck and osteomyelitis, affected his speech and he lost a significant amount of weight. Mrs A said Mr A’s hands have also been affected as his hands are continuously in pain and throbbing which has left him unable to work.
40. The Trust said skull base osteomyelitis is a rare but potential complication and is not due to an error made during Mr A’s surgery. The Trust said it did not suppress a nerve during Mr A’s adenoidectomy. The Trust said Mr A suffered a post-operative infection (osteomyelitis) and this was the cause of Mr A’s subsequent symptoms.
41. The Trust said due to the ongoing osteomyelitis infection Mr A developed right hypoglossal nerve palsy. The hypoglossal nerve controls movement to the tongue. In this case Mr A’s right hypoglossal nerve stopped functioning. The Trust said this nerve cannot be damaged during an adenoidectomy due to its location being significantly far away from the surgical site.
42. RCOS good surgical practice says doctors should carry out surgical procedures in a timely, safe and competent manner. The NHS webpage on adenoidectomy says this procedure should be performed under general anaesthetic. It explains the surgeon removes the adenoids through the mouth and they will either be carefully cut out or removed using special tools.
43. From the records we can see Mr A attended the Trust on 6 July for an adenoidectomy. We can see Mr A was placed under general anaesthetic and the Trust performed the surgery endoscopically.
44. In the operation notes we can see the Trust noted it located Mr A’s adenoids and ‘powered adenoidectomy completed’. A powered adenoidectomy is when the surgeon uses a powered tool which has a small rotating tip to remove the adenoids. The Trust documented it also used suction cautery. Suction cautery is an instrument that uses heat to burn away the adenoid tissue.
45. We recognise Mrs A has informed us the Trust suppressed a nerve in the back of Mr A’s head during surgery. We understand Mrs A has told us she was informed this by the staff member that performed the surgery. We are not able to take a view on what was said, or more importantly what was understood, during this discussion due to a lack of evidence. We understand Mrs A will be upset by this, and we are sorry for any further upset we may cause here.
46. We can see the Trust admitted Mr A overnight and he was discharged the following day. We can see following his discharge Mr A attended the Trust on multiple occasions complaining of headache, earache and throat pain.
47. We can see Mr A was admitted to the Trust on 26 August with nausea, difficulty swallowing, a change in voice and difficulty with speech. The Trust performed a CT scan which showed post-operative infection with secondary skull base osteomyelitis which is an infection in the central base of the skull.
48. We can see Mr A first presented with issues regarding his speech on 26 August, approximately five weeks following the adenoidectomy. At this time, the Trust documented Mr A’s hypoglossal nerve was intact. Our adviser said this symptom appeared a significant amount of time following surgery and this change was prompted due to the underlying infection. On 31 August the Trust informed Mr and Mrs A that the hypoglossal nerve was likely damaged due to the infection and inflammation of the osteomyelitis.
49. Our adviser explained that the hypoglossal nerve is inaccessible during adenoid surgery as it is located much deeper than the surgical site. Our adviser said the nerve was not suppressed during surgery, but it was affected by the skull base infection which would have caused localised swelling.
50. We have not seen any indication the Trust suppressed Mr A’s nerve during surgery. We think Mr A’s hypoglossal nerve function was impacted by the osteomyelitis and was not due to an error made during surgery. This is supported by the symptoms relating to nerve damage not appearing for five weeks following surgery and the nerve being inaccessible during adenoid surgery. We recognise Mrs A does not agree with this and we are sorry for any distress this may cause.
51. From the evidence we have seen, we think the Trust has acted in line with RCOS good surgical practice. We can see the Trust clearly documented the surgical techniques used during the adenoidectomy. Our adviser said the Trust used a well-established and appropriate technique.
52. We have not seen any indication anything went wrong during the surgery and Mr A was discharged home. We provisionally find this is in line with RCOS good surgical practice which says surgical procedures should be carried out in a safe and competent manner.
53. We understand Mr and Mrs A have been through an extremely difficult time. Our adviser said osteomyelitis is an incredibly rare complication and we do not underestimate the impact this had and continues to have on them both. We understand why Mrs A was concerned the Trust did not appropriately conduct the adenoidectomy, particularly as she has told us the Trust informed her it had suppressed a nerve. We have not seen any indication the nerve was suppressed during the adenoidectomy.
54. We acknowledge how distressing these events were and that this is not the decision Mrs A was hoping for. We hope our decision provides reassurance to both Mr and Mrs A that there is no indication Mr A’s nerve was suppressed and the surgery was carried out appropriately.
Communication
55. Mrs A said due to the medication her husband was taking, he was confused a lot of the time and could not understand what the doctors or other staff members were telling him. Mrs A said she asked for staff to communicate with her about Mr A’s condition due to his confusion, but this request was ignored.
56. GMC good medical practice says doctors must give patients the information they want or need to know in a way they can understand. Doctors must also be considerate to those close to the patient and be sensitive and responsive in giving them information.
57. We will first look at the communication provided to Mrs A from 26 August to 14 September and 15 September to 22 September.
58. From the records we can see on 30 August the Trust informed Mrs A and her daughter that Mr A had osteomyelitis which is a post-operative infection. The Trust informed Mrs A that Mr A’s speech had been affected due to the nerve supplying the tongue being damaged by the inflammation caused by the infection. The Trust noted Mrs A thanked them for the update.
59. On 2 September we can see the Trust discussed the plan of care with Mr A. The Trust explained that Mr A would be discharged with community IV antibiotic therapy. The Trust noted Mr A was happy with this plan.
60. The following day we can see Mrs A raised concerns to the Trust that she was unhappy with the communication between doctors and family. Mrs A requested a doctor call her to provide an update. We can see a nurse provided an update and requested a doctor call her back. The rhinology fellow contacted Mrs A on 5 September and documented they had a very detailed discussion with Mrs A and that she was up to date with the management plan and was happy with it.
61. We can see on 13 September Mrs A raised concerns to the nurse that she didn’t understand why Mr A was in hospital and what had been done. The nurse requested for the doctor to speak to the patient and noted the doctor had done this.
62. On 14 September the Trust discharged Mr A with six-week course of antibiotics and explained this to Mrs A.
63. Mr A was admitted back to the Trust the following day due to feeling generally unwell with nausea and diarrhoea. The Trust noted it was likely an adverse reaction to the antibiotics and commenced IV antibiotic treatment.
64. We can see on 17 September following a doctor’s review Mr A asked the Trust to contact his brother-in-law to update him. We can see this discussion took place on 18 September with a detailed update provided to Mr A’s brother-in-law.
65. We can see on 22 September following a doctor’s assessment it noted Mr A could be discharged as he had no adverse reaction to the new antibiotics. We can see the Trust provided an explanation to Mr A on the medication he was being discharged with and it explained this was due to his osteomyelitis and sickness.
66. From the evidence we have seen so far, we think the Trust has acted in line with GMC good medical practice during these admittances. We can see the Trust explained to Mrs A that Mr A had osteomyelitis and explained how this had impacted his speech.
67. It is very difficult for us to form a view on what has been understood during a discussion. We can see the Trust documented it had provided a clear update to Mrs A on 30 August, however on 13 September Mrs A reported not knowing why Mr A was in hospital. We understand this is a complex condition and it is understandable that Mrs A may not have fully understood what the doctor had told her.
68. We have also seen the Trust was providing regular updates to Mr A during both these admittances. We have not seen any indication Mr A was confused or unable to retain the information he was given during this time. Due to this we do not think providing information to Mr A instead of contacting his wife is an indication of a failing. We think this is in line with GMC medical practice which says doctors should be responsive in the information it provides.
69. We will next look at Mr A’s admittance from 17 October to 3 November.
70. We can see Mr A presented to the Trust on 17 October with a three-day history of feeling unwell, vomiting, diarrhoea and a general decline with worsening speech. We can see the Trust performed an assessment of Mr A with Mrs A present. The Trust documented it would provide IV fluids to Mr A and continue his antibiotic treatment. The Trust noted it would discuss Mr A’s symptoms with the infection service.
71. On 18 October we can see Mrs A contacted the Trust and an update was provided. We can see the infection service reviewed Mr A and noted to stop oral antibiotics if he was vomiting and continue to administer antibiotics via IV until sickness settles.
72. On 20 October we can see Mrs A requested an update and the Trust provided this.
73. We can see the Trust planned to conduct an MRI on 22 September, but this did not take place. We can see on 23 September the Trust discussed the MRI with Mrs A and noted it would chase this.
74. On 24 October we can see Mrs A raised concerns to the doctor that Mr A’s short-term memory was impaired. Mrs A said she was worried that information was being given to Mr A regarding his condition and treatment that he was not passing on to her. We can see the doctor noted discussions regarding Mr A’s ongoing treatment should be had with Mrs A if possible.
75. On 25 October we can see the Trust performed an MRI and noted the infection area was largely unchanged from August.
76. On 27 October we can see the Trust provided an update to Mrs A and Mr A’s brother-in-law. We can see the Trust explained the concerns it had regarding Mr A and that it had requested a CT scan. We can see the Trust also advised it planned to conduct ENT debridement surgery on 31 October which is surgery to remove the infected bone and tissue caused by the osteomyelitis. The Trust documented Mrs A was happy with this plan and had no further questions.
77. We can see the CT scan was completed on 28 October and Mrs A was present on the ward. Mrs A asked a nurse if the doctors could call her during ward rounds. We can see the nurse provided the ward number to Mrs A and advised her to call the ward for any updates.
78. On 31 October we can see the Trust was unable to perform the surgery and a doctor discussed the reasons for this with Mrs A. We can see the doctor also discussed Mr A’s CT scan results with Mrs A. Mrs A raised concerns that Mr A had not had a medical review that day and we can see the on-call registrar was requested to review Mr A.
79. We can see the registrar contacted Mrs A by phone the same day and provided an update. They noted Mrs A was grateful for the update and had no further questions.
80. We can see Mr A’s surgery was conducted on 1 November and Mrs A was present on the ward during his recovery. On 2 November we can see the Trust discussed Mr A with Mrs A and provided an update on his condition. The Trust discharged Mr A on 3 November.
81. From the evidence we have seen, we think the Trust has acted in line with GMC good medical practice. We can see the Trust provided regular updates to Mrs A during this admittance. We can see Mrs A raised concerns that Mr A was not retaining information, and the Trust requested for any ongoing treatment to be discussed with Mrs A which it appears it did. We think this is in line with GMC good medical practice which says to be sensitive and responsive when providing information to family members.
82. Lastly, we will look at Mr A’s admittance from 28 November to 16 December.
83. We can see Mr A attended the Trust on 28 November feeling generally unwell with itchiness, poor appetite and a change in attitude. The Trust queried whether it was a reaction to the antibiotics. We can see the Trust conducted an examination of Mr A on 29 November with his wife present and discussed his current condition and plan of care.
84. We can see the Trust planned to conduct an MRI on 1 December, but this was cancelled due to a power cut. The Trust noted it informed Mr A of this.
85. On 2 December we can see the Trust spoke with the MRI control room who advised that due to demand, Mr A’s MRI may need to be conducted as an outpatient. We can see shortly after this Mrs A called the ward requesting an update on Mr A’s MRI. We can see the Trust provided an update and reassurance to Mrs A and noted she was happy with this.
86. We can see the Trust re-requested an MRI on 3 December and this took place on 4 December. On 5 December we can see the Trust reviewed the MRI report and noted it showed the skull base collection (the infection site) was stable with a slight increase of thickness to the skull base wall. We can see Mrs A requested an update from the nursing staff and the nursing staff requested a doctor contact Mrs A.
87. We can see a doctor contacted Mrs A on 6 December and discussed the MRI results and recommended a further debridement surgery. Mr A advised he would speak to his brother-in-law who is a surgeon regarding this. We can see the doctor discussed this surgery with Mr A’s brother-in-law on 7 December and following discussion the Trust began planning for surgery.
88. We can see Mr A’s surgery was scheduled for 9 December, but this was cancelled due to emergency cases taking priority, and the Trust informed Mr A of this. We can see the surgery was scheduled again for 11 December, but this again was cancelled due to emergency cases. We can see the Trust explained this to Mr and Mrs A.
89. We can see Mr A’s surgery took place on 12 December and the Trust tried to contact Mrs A by phone but there was no answer. We can see Mrs A was present on the ward on 13 December.
90. On 14 December Mrs A requested an update from a doctor. We can see a doctor contacted Mrs A and provided an update. We can see Mrs A raised concerns about Mr A’s memory and the Trust advised it did not feel there was an issue with Mr A’s memory. The next day Mrs A requested a call from a doctor with an update and this was provided on 16 December. Mr A was discharged on the same day, and the Trust noted he left the hospital with family members present.
91. We have received conflicting information regarding Mr A’s memory and his ability to retain information. We understand Mrs A has told us her husband was confused and not able to pass information on. We can see during Mr A’s 17 October to 3 November admittance the Trust was providing information directly to Mrs A due to Mr A’s reported memory issues.
92. During this final admission, the Trust noted it did not feel there was an issue with Mr A’s memory. It therefore seemingly continued to provide information to Mr A instead of Mrs A. It is difficult for us to say this is an indication of a failing as it is the clinician’s judgement of Mr A’s condition, and we have seen nothing to suggest this judgement was unreasonable.
93. From the evidence we have seen so far, we think the Trust has acted in line with the GMC’s good medical practice. We acknowledge that during this admittance Mrs A was having to contact the Trust for updates more often than previously, and the Trust was not pro-actively providing updates.
94. We understand this would have been frustrating for Mrs A. Our adviser explained that the communication could have been better during this last admission. We acknowledge that the communication could have been more forthcoming from the Trust. We do not think the communication was so poor that it fell below the level expected by the general guidance.
95. We can see that on each occasion Mrs A requested an update from a doctor, this was provided either the same day or the next day depending on availability. We can see during these discussions the Trust was providing updates and noted Mrs A was happy. We recognise these discussions were initiated by Mrs A and we are not able to say what the communication would have been like if Mrs A was not regularly contacting the Trust.
96. We recognise this decision will be very upsetting for Mrs A. We understand Mrs A was extremely worried about her husband and does not feel the Trust communicated with her effectively. It is not our intention to cause Mrs A any further distress by our decision.
97. We think overall the communication provided to Mrs A was in line with GMC guidance. We can see the Trust was providing regular updates to Mrs A and it responded to each request for it to contact Mrs A directly in a timely manner. We think this is in line with GMC good medical practice.