13. 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.
Follow up appointment and communication after surgery
14. Mr B told us he did not see his surgeon after the HALO procedure was performed and next saw him at an outpatient appointment in June 2024. He says the surgeon was unaware he had been back in hospital.
15. Mr B complained to the Trust that the surgeon and their secretary did not respond to emails his wife sent. The Trust’s complaint response apologised for this poor communication.
16. The NICE guidance ‘Haemorrhoidal artery ligation’ explains when haemorrhoid surgery is indicated, how the procedure is carried out and the specific complications which can develop as a result of this. This guidance does not suggest a follow up consultation is indicated after the surgery. Our adviser also confirms there is no national guidance which specifically sets out the need for a follow up consultation.
17. We have considered Mr B’s discharge summary on 16 April 2024. This says there would be no planned follow up in a surgical clinic and Mr B was given appropriate safety netting advice and was told what to do if he had concerning symptoms. Our adviser explained the lack of a planned follow up was appropriate, as if a patient has a problem, it is usually soon after surgery and would require the patient to have an assessment in accident and emergency (A&E). They explained a planned follow up would not prevent this from happening.
18. Our adviser explains that if a patient does not have issues, then a planned follow up clinic would serve no purpose beyond providing reassurance.
19. Our adviser also explains that following Mr B’s admission on 29 April 2024, tests and investigations were completed, and the team knew his symptoms would start to lessen with time.
20. Overall, we have not seen indications to suggest a follow up appointment was missed for Mr B. We hope our explanation provides Mr B with some reassurance.
21. Mr B explains his wife also tried to contact his surgeon directly after his surgery to raise concerns about his pain. We appreciate the lack of response would have caused anxiety and stress in addition to the significant pain Mr B was experiencing.
22. We have considered the actions the Trust has taken in line with our ‘Complaint standards’. These say organisations should explain why things went wrong and identify suitable ways to put things right for people. It says staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
23. We can see that the Trust apologised to Mr B for these communication issues on 9 August 2024. It also stated it had taken the importance of timely communication and response to patient needs as a lesson learned and that this would be shared within its general surgery department through discussion with the recovery clinical lead and through a general surgery clinical governance meeting.
24. We consider the Trusts actions are appropriate to address the communication issues experienced with Mr B’s surgeon we have seen and are in line with our ‘Complaint standards’. We therefore do not consider further action is needed in relation to this concern.
Complications and further surgery
25. Mr B told us he believes some stitches were removed in a second procedure. He was not told the further procedure was to rectify any issues with the first.
26. Mr B attended A&E on 29 April because he was experiencing a significant amount of pain post-surgery and was admitted to hospital until 7 May 2024.
27. The Trust told us it performed a flexible sigmoidoscopy (diagnostic procedure to examine the lower part of the colon and rectum) under anaesthetic on 1 May. No active bleeding was found and a loose suture was removed.
28. Our advisor explained this further procedure was a diagnostic examination which was performed under general anaesthetic as Mr B was too sore to be properly examined awake. The procedure and all scans showed normal post operative findings. The loose suture that cut through may have amounted to some rectal bleeding but was not responsible for the pain Mr B was experiencing.
29. The NICE guidance sets out some of the known complications of the HALO procedure. This can include sutures being placed too low in the anal canal, which can cause severe pain. Our adviser explains the Trust considered this as a possible cause for Mr B’s pain, and the sigmoidoscopy confirmed the sutures had been placed correctly during Mr B’s first surgery.
30. We have seen no indication there were complications following Mr B’s procedure or a further surgery was required to rectify complications. The procedure Mr B had post-surgery was a diagnostic examination, rather than further surgery.
31. The removal of a stitch was not linked to the pain Mr B suffered. We appreciate it may have felt like a further procedure to Mr B, as the Trust did it under general anaesthetic due to the level of pain he was in. We have seen no evidence to suggest further surgery was carried out to rectify the first surgery.
Nerve damage
32. Mr B told us he was told a stitch or two too many may have been used in his first surgery. He believes a nerve might have been stitched or stitches may have caused nerve damage. Mr B told us the pain in his rectum resolved at the end of September 2024.
33. As above, the Trust acknowledged a loose suture was removed when Mr B was examined under anaesthetic but does not acknowledge that stitches had been inappropriately placed.
34. The Trust response says Mr B underwent a number of investigations when he was admitted which showed typical post-HALO appearances. The response also says it is difficult to predict the post operative course of the procedure, but it can be an incredibly painful process and pain like Mr B experienced is a possibility. It said patients should be aware this may be the case and apologised that Mr B was not made aware of how painful it could be.
35. Our adviser explained Mr B did not have nerve damage and the pain he experienced was neuropathic, which means there was no explanation for it other than hypersensitive nerves.
36. Our adviser told us this is a well recognised cause of pain after all haemorrhoid surgery and the HALO procedure, particularly for larger haemorrhoids, can cause severe pain. He explained that Mr B had very large grade four prolapsing haemorrhoids. Grade four is the most severe, and bigger haemorrhoids are harder to treat.
37. Our adviser explained when the surgeon mentioned nerve damage they were trying to explain the cause of Mr B’s pain was likely neuropathic. He told us it is not technically possible to trap the nerve in a suture from the HALO procedure.
38. Our adviser also noted that the stitches used in the HALO procedure are dissolvable and it is not uncommon for some to become loose or cut through the swollen tissue.
39. Our adviser also told us Mr B’s pain was managed in a sensible and logical fashion. The Trust carried out investigations to exclude specific complications in line with the NICE guidance and specialists from the pain team were involved in Mr B’s care. The Trust prescribed Mr B with laxatives, nerve numbing medication, pregabalin, alongside regular pain medication, which is in line with the strategies for managing post operative pain we have seen in ‘Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review’.
40. In addition, the NHS England guidance ‘Evidence based interventions: Surgery to treat haemorrhoids’ and ‘Advice after a HALO procedure for haemorrhoids’ explains risks of haemorrhoid surgery include pain and that medication may need to be prescribed in addition to over-the-counter pain killers. The Academy of Medical Royal Colleges guidance ‘Haemorrhoid Surgery’ says pain and bleeding that may persist for several weeks is a common complication of haemorrhoid surgery.
41. Overall, we have not seen indications to suggest Mr B experienced nerve damage following the procedure on 16 April 2024.
42. We do not doubt Mr B’s account of the pain he experienced and note the HALO procedure is recognised to cause significant pain, particularly for large haemorrhoids, and Mr B has told us about the significant pain he suffered.
43. We have considered the actions the Trust has taken in line with our ‘Complaint standards’. These say organisations should explain why things went wrong and identify suitable ways to put things right for people. It says staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.
44. In addition to apologising to Mr B for not making Mr B aware of how painful the procedure could be the Trust stated it had taken the importance of preparing patients and managing postoperative pain expectations prior to surgery as a lessen learned, and that this would be shared within its general surgery department through discussion with the recovery clinical lead and through a general surgery clinical governance meeting.
45. We consider the Trust’s actions are appropriate to address failing to inform Mr B how painful the post operative course from the procedure can be and are in line with our ‘Complaint standards’. We therefore do not consider further action is needed in relation to this concern.
46. We have seen not seen indications to suggest Mr B’s pain was not managed appropriately.
Delay in prescribing ointment, anal fissures, and lack of post operative care
47. Mr B told us he expected ointment for anal fissures to be prescribed when he was discharged following his first surgery on 16 April because they are a common occurrence after the HALO procedure. He told us his fissures resolved after being prescribed the ointment. He also told us he feels there was a lack of post operative care.
48. The Trust response explains anal fissures are a very common complication of any anal surgery and says the ointment was eventually helpful and accepts it would have been useful if it was prescribed a little earlier. It also states the matter would be discussed at a departmental clinical governance meeting
49. Our adviser explained Mr B received appropriate post operative from the Trust. They also explained that no anal fissures were noted during Mr B’ second procedure, and it is common to get micro fissuring in relation to all the swelling in the area after the HALO procedure.
50. Our adviser said the fissure medication was prescribed to try and generally reduce muscle spasm in the area and sometimes anal fissure medication can help with anal pain even in the absence of a fissure, as the medication acts to relax the anal sphincter muscles.
51. Our adviser explained the ointment was an extra thing prescribed to try and help control Mr B’s symptoms.
52. Our adviser said there is no guidance to suggest the ointment should be prescribed after a haemorrhoid operation, but it is reasonable to try it as an extra way of trying to reduce symptoms.
53. Our adviser also told us Mr B’s pain was managed in a sensible and logical fashion.
54. We have seen no indication there was no post operative care. Mr B was initially discharged with strong pain killers and laxatives. The Trust carried out investigations to exclude specific complications and specialists from the pain team were involved in Mr B’s care.
55. We understand that Mr B was in a significant amount of pain following the procedure and are glad to hear that the pain has now resolved.
56. Overall, we have not seen indications to suggest there was a delay in prescribing the ointment and we have not seen this would have changed the micro fissuring Mr B experienced.
57. The Trust has acknowledged the ointment could have been prescribed earlier. This would not have prevented Mr B from getting an anal fissure but could have provided additional pain relief. Upon reviewing the evidence, we see the Trust has done enough to put right the impact this had on Mr B.
Conclusion
58. We thank Mr B for bringing his concerns to us and hope our statement reassures him about the care he received.