26. 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 found any indications that something has gone wrong.
Investigations and treatment
27. Mr U says he had pain from his neck down to his toes following his accident. He says the Trust’s investigations, scans and X-rays only focused on his lower back. He says the Trust did not explore, scan or X-ray other parts of his body in detail, particularly his left leg and knee where he also had pain. He believes he should have had a full body scan.
28. Mr U says the orthopaedic consultant told him they believed it was a spinal issue which is why the imaging was on his spine. The Trust did not respond specifically to this in its complaint responses.
29. He also says the consultant spinal surgeon did not correctly diagnose and treat his symptoms.
30. We are sorry to hear Mr U’s pain did not improve and that the mobility in his leg got worse.
31. The Trust said the consultant provided the correct treatment for Mr U’s symptoms . It said, as he did not have ongoing leg pain, the consultant advised him not to proceed with the surgery on 16 March 2022. The Trust did an investigation of the treatment on 26 January 2023. This concluded that the treatment plan was in line with best practice and that the consultant was right not to go ahead with decompression surgery.
32. Mr U’s GP referred him for an X-ray on the lumbar area of his spine and an MRI scan of his lumbar and sacral spine. The lumbar area is the lower part of the spine and consists of five spinal bones (vertebrae). The sacral spine is connected below the lumbar spine, and consists of five vertebrae which are joined together to form a large triangular shaped bone.
33. Mr U had the X-ray at the Trust on 4 September. The report says he had sciatica type pains and paresthesia. Paresthesia is numbness or pins and needles sensation.
34. NHS online explains sciatica happens when the sciatic nerve, which runs from the lower back to the feet, is irritated or compressed. It says the most common cause of sciatica is a slipped disc. This is where the soft cushion on tissue (disc) between the vertebrae pushes out. This says, if someone has sciatica their bottom, back of their leg, foot and toes may feel: • pain which may be stabbing burning or shooting • tingling like pins and needles • numbness, and • weakness.
35. The X-ray report says Mr U had degenerative changes (changes over time) in the lumbar spine, the vertebrae were normal, and no injury to the bones.
36. He then had the MRI scan on 20 October which showed one of his lumbar discs was bulging out from where it should be (herniated) and pressing on a nerve on the left side of his spine.
37. Mr U’s GP then referred him to the Trust on 10 November. In this referral the GP said Mr U had lower back pain radiating down his left leg. The GP said the MRI results accounted for this sciatica pain.
38. Following his first telephone appointment with the consultant orthopaedic surgeon on 20 December. The consultant recorded that Mr U had sudden onset left sided back pain going down his left leg into his big toe. The notes say he reported numbness and weakness in the leg. The consultant said the slipped disc shown on the MRI scan was the likely cause of his symptoms.
39. Our adviser said the symptoms Mr U had, were classic symptoms of sciatica, in line with the NHS online information. They said the initial MRI scan results were consistent with this.
40. Our adviser explained that once a patient has been referred to a specialist, that spinal surgeon decides if any further investigations are needed. They said, as recent X-rays had already been taken, and the MRI results showed the compressed nerve, the surgeon did not need any further imaging at that time to know what the problem was. Our adviser said the diagnosis is supported by the records and was made following appropriate investigations and considerations.
41. NICE guidance says if oral medication does not relieve acute and severe sciatica, clinicians should consider non-surgical treatments including epidural injections of local anaesthetic and steroids. Epidural is the space around the spinal nerves.
42. As medication had not relieved Mr U’s sciatica symptoms, the consultant listed him for lumbar root nerve block. This is an epidural injection of local anaesthetic and steroids. The Trust gave this to Mr U on 20 April 2021. We consider this was in line with NICE guidance and our adviser said this treatment plan is also in line with generally accepted good practice for spinal surgeons.
43. NICE guidance says, ‘Consider spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms.’ NHS online for sciatica says decompression surgery can sometimes help relieve sciatica.
44. The consultant had a telephone appointment with Mr U on 19 August 2021. This included discussion around discectomy surgery. This is a surgical procedure to remove part of, or all of a damaged/herniated spinal disc. The consultant listed Mr U for this surgery and a further MRI scan.
45. Our adviser explained that spinal surgeons often refer to decompression and a discectomy as the same thing. They said spinal decompression is where the surgeon makes a window in the spine by cutting away bone and ligaments which reduces the pressure on the nerve. The surgeon moves the nerve to see if there are any disc fragments and if there are, they remove them if this is safe to do so. They said a discectomy depends on what the surgeon finds inside when doing the decompression.
46. Our adviser said the notes indicate that the consultant’s plan was to do decompression with a view to a possible discectomy. We consider this plan to be in line with NICE guidance.
47. Following the telephone appointment with Mr U, the consultant wrote to his GP and explained there was a 90% chance of the discectomy relieving Mr U’s leg pain.
48. The Trust admitted Mr U on 16 March 2022 for the discectomy. The notes indicate he did not have any leg pain at that time although he did have some weakness and numbness. The notes indicate the consultant advised Mr U a discectomy would not likely improve these symptoms. As he did not have leg pain, the notes indicate they discussed that the surgery should not go ahead.
49. As indicated by NHS online and NICE guidance, our adviser said the aim of decompression/discectomy is to reduce the pressure on the nerve and to improve the symptoms of leg pain. They said, as in Mr U’s case, if a patient is no longer in pain but the nerve is still compressed, the chance of this surgery improving the condition is very low.
50. Our adviser said there is no specific guidance in relation to whether to complete the decompression/discectomy. They said this is a clinical decision for the surgeon, following consideration of the likely risks and benefits. They went on to say they would not have offered the surgery to Mr U in these circumstances because the risks involved would outweigh the low chances of any benefit. Our adviser says they agree with the surgeon’s decision not to continue with decompression/discectomy.
51. To summarise, we consider the Trust diagnosed, investigated and treated Mr U’s condition in line with NHS, NICE guidance and established best practice. For these reasons, we will not be investigating this further.
Timeliness of treatment
52. Mr U says Trust took too long to diagnose and treat his symptoms. He also says it did not provide face to face appointments.
53. We appreciate how frustrating it was for Mr U when his treatment was delayed. We are sorry to hear this meant he was in pain for an extended period and that this affected his mental health.
54. In its complaint response, the Trust said the first consultation in December 2020 was by telephone rather than face-to-face because of directives from the Department of Health during the COVID-19 pandemic. It said the surgeon could not list him for surgery at that time because of this. It went on to say these directive caused severe backlogs in treatment and this was out of its control. The Trust said had it not been for the pandemic, it may have been able to offer surgery sooner which may have relieved his pain. It said, however, the delays in his treatment were unavoidable.
55. Mr U’s GP sent the Trust a referral on 10 November 2020. They marked the priority of this referral as ‘routine’.
56. The NHS’s guide to waiting times says the maximum waiting time for non-urgent, consultant led treatment is 18 weeks from the day of referral.
57. The Trust provided Mr U his first appointment by telephone on 21 December during which the consultant confirmed his symptoms, diagnosis and listed him for lumbar root nerve block. This was all within 18 weeks of the GP’s referral. For these reasons, we consider the Trust acted within NHS waiting time guidelines.
Timeline of the COVID-19 pandemic 58. The UK government introduced social contact restrictions and national lockdowns during the COVID-19 pandemic. It gave advice on restricting travel on 16 March 2020 and then introduced a full national lockdown on 26 March.
59. On the 17 March, NHS England wrote to all NHS trusts with plans for the pandemic. In this it said Trusts should postpone all non-urgent surgery for at least three months.
60. The government eased the lockdown in July whilst social distancing remained.
61. On 5 November, a second national lockdown came into force. Lockdown ended on 2 December with restrictions remaining.
62. A third national lockdown was introduced on 6 January 2021. The government lifted this from March 2021 however all restrictions were not lifted until 19 July.
63. On 8 December, the government announced social restrictions. It lifted all restrictions on 21 February 2022.
64. Unfortunately, The Trust received the referral after the first lockdown and when the second one was in place. We know the NHS already had a significant backlogs from non-urgent treatment being paused and not being able to offer face-to-face appointments because of restrictions. The notes show Mr U’s GP could also not offer face-to-face appointments when he spoke with them between August and September 2021.
65. We consider the Trust provided him with treatment in line with NICE, GMC and NHS guidelines despite the lockdowns, restrictions and subsequent growing waiting lists it was facing. This is because throughout this challenging time for the NHS, the Trust provided ongoing treatment to Mr U.
66. It provided telephone consultant appointments, a root nerve block injection, telephone physiotherapy services and, when this had not worked, a further MRI scan and an appointment for spinal decompression. For these reasons, we do not consider the Trust did anything wrong in relation to the timescales for his treatment and we will not be investigating this further.
67. Our adviser said, even if the Trust had been able to offer Mr U the decompression/discectomy earlier, it would only have had potential benefits in relation to the pain he was in at that time and it is very unlikely it would helped with the weakness he reported in his leg. We hope this provides him with some reassurance.
Follow up after discharge
68. Mr U complains that the Trust’s discharge letter says the consultant would see him for follow up three months later but this did not happen. Mr U has not complained to the Trust about this specifically.
69. We are sorry to hear this has left him feeling distressed and uncertain about his condition.
70. The clinical notes for the cancelled decompression surgery and letter to the GP indicate the plan was for Mr U to have a follow up appointment with the orthopaedic department in three months’ time.
71. There is no evidence to suggest the orthopaedics department made a further appointment following Mr U’s discharge. We spoke with the Trust and it confirmed it has not seen him since then. The consultant said Mr U did not need a follow up appointment as his foot mobility would not improve and there was no intention to treat him further. The Trust indicated the letter was an administrative oversight.
72. There is no specific guidance which says what should have happened in these circumstances. Our adviser said, whilst the consultant could have offered a follow up appointment to advise Mr U on his condition, they do not consider that the consultant needed to do this in these circumstances.
73. They said this is because the consultant had advised against decompression surgery and there would be minimal benefit to a further surgical follow up. They went on to say Mr U’s rehabilitation at this stage would likely be under the care of his GP and physiotherapists. They added that, in their professional opinion the lack of follow up has had no effect on Mr U’s outcome.
74. The NHS Constitution says, ‘The NHS belongs to all of us. There are things that we can all do for ourselves and for one another to help it work effectively.’ It also says, ‘Please recognise that you can make a significant contribution to your own, and your family’s, good health and wellbeing, and take personal responsibility for it.’ It goes on to say, ‘Please give feedback – both positive and negative – about your experiences and the treatment and care you have received’.
75. We appreciate this was a worrying time for Mr U, particularly after the surgery he had hoped would improve his condition was cancelled.
76. After the surgery cancellation, he complained to the Trust about his treatment. However, he did not complain to the Trust about a lack of any follow up appointment or make it aware he had not had a follow up. As such, the Trust did not have opportunity to reply or to correct this if it felt this was necessary.
77. Mr U told us he has not requested any further assessment or treatment from the Trust or his GP in the three years since his discharge.
78. The Trust could have offered a follow up appointment as it had outlined in the discharge letter. However, this is not something it had to do. As such, we will not be investigating this part of his complaint further. Not offering it is not so serious that it amounts to a service failure. We do however recognise that because it was mentioned in the discharge letter, Mr U has been left with some uncertainty and disappointment. We hope he is reassured that the follow up appointment was not essential.
79. We are grateful to Mr U for bringing his complaint to us. We appreciate the loss of mobility of his leg has caused him a great deal of distress. We would encourage him to speak to his GP to explore any support which may be available to him.