Royal Devon University Healthcare NHS Foundation Trust

3. Mrs S complains about the following care and treatment she received from the Trust in February and August 2024 after she had undergone spinal surgery:

•a senior spinal fellow (SSF) incorrectly decided to discharge her from the spinal team at the Trust in February 2024. She says when making this decision, they did not consider all the post operative symptoms she was experiencing.

•an SSF did not put sufficient information in her discharge letter so she could get access to support she needed at work. She says it prevented her from accessing care and treatment relating to the symptoms she was experiencing as well as certain benefits such as a blue badge.

•an SSF told her she had damaged the cervical area in her neck but this would not cause the symptoms she was having. She states the discharge letter did not explain this and was too vague.

•when her GP tried to refer her back into the spinal services in August 2024, an SSF did not acknowledge the referral, failed to process it or record the call.

As a result, Mrs S says she feels her concerns have been dismissed and she has not been able to access proper care and treatment for the symptoms she continues to experience. She states these events have caused her distress as she felt at the time nobody believed the symptoms she was experiencing. She told us this put a significant strain on her personal relationships. Mrs S says because her referral was not processed correctly in August 2024, she was further denied access to support and treatment for her pain.

She states she has had to have counselling and takes medication to help with depression and panic attacks because of the events following surgery. Mrs S advised she has had a total lifestyle change and now suffers with exhaustion and fatigue and has been retired from her job due to ill health. She has had to buy a mobility scooter to get around and complete daily tasks.

4. By bringing this complaint to us, Mrs S is seeking: • an acknowledgement the decision to discharge her from the Spinal Team in February 2024 was incorrect • an acknowledgement the SSF’s failure to process her referral in August 2024 stopped her from getting the care, treatment and support she needed for symptoms • financial remedy

5. Mrs S underwent a laminectomy (surgery to relieve pressure on the spinal cords and nerves) at the Trust in June 2023. Following surgery, her pain persisted, and she suffered new and ongoing symptoms of numbness in her right leg, headaches, pain in her left arm and shoulder and in her neck.

6. In January 2024, Mrs S had MRI scans of her spine and head. She had a further MRI scan and appointment with her surgeon and orthopaedic consultant in February 2024 for her left shoulder. The orthopaedic consultant suggested Mrs S may be suffering from frozen shoulder due to prolonged surgery.

7. In February 2024, an SSF who was covering for Mrs S’s treating surgeon, saw Mrs S and shared the details of her spinal MRI with her. This showed degenerative changes in the cervical spine but no compression. The SSF told Mrs S she would probably need to integrate these symptoms into her life. He made a referral to the Pain Management Team.

8. In March 2024, another spinal surgeon reviewed an MRI scan of Mrs S’s shoulder and head. They said the results did not show anything concerning.

9. Following the letter of February 2024, Mrs S sought medical help for symptoms through her GP. She had various tests and was referred to various specialties (blood tests, chest x-ray, referral to breast care, rheumatology and urology) with no explanation for her symptoms and continued pain.

10. In June 2024, Mrs S had spinal and left shoulder MRI scans done privately. The spinal MRI reported spondylotic changes with multilevel nerve impingements (wear and tear on the spine where the bones or discs are pressing on nearby nerves). The shoulder MRI reported mild AC joint degeneration (the joint at the top of the shoulder had some wear and tear). These results were shared with her GP.

11. In July 2024, Mrs S had a fall and began experiencing pain in her pelvis and difficulty standing.

12. In August 2024, her GP suggested going back to the Trust and made a call to the SSF. The GP recorded the SSF refused the referral saying there was no acute operative intervention they could offer at the time, but they were happy to see Mrs S in clinic. The Trust’s responses to Mrs S state the SSF has no memory or record of the call.

13. In November 2024, after receiving a complaint from Mrs S, the SSF discussed Mrs S’s case in a Multi Disciplinary Team meeting (MDT) which decided no spinal intervention or anything surgical was needed.

Discharge from the spinal team

17. 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 indications that something has gone wrong.

18. Mrs S believes she was incorrectly discharged from the care of the spinal team at the Trust in February 2024. We approached the Trust to confirm the letter from the SSF was a discharge letter. The Trust advised us it does not recollect any comments from the SSF regarding discharging Mrs S. It said criteria for discharge would normally be based on symptom improvement, completion of surgical plan or if there is no further surgical input required (or where a further opinion has been sought).

19. Mrs S’s GP records show during a call to the Trust in August 2024 the Trust stated it would be happy to see her in clinic again but could not see her that day. However, the Trust state this call did not take place. We can also see from the Trust’s complaint file, in an email from November 2024, it suggested Mrs S could been seen in clinic again to go over her symptoms if that would be helpful. We cannot see that Mrs S was ever told directly she could be seen in clinic again.

20. We have not been able to confirm whether Mrs S was discharged from the spinal team at the Trust. We believe communication broke down between Mrs S and the Trust and this led to a misunderstanding about whether she was still considered under the care of the spinal team.

21. The Guidelines list several ways to manage back pain before more invasive treatment, including pain management. The Trust had decided Mrs S was not suited to further surgery and referred her to the Pain Management Team and our adviser says this is in line with the Guidelines. After Mrs S’s surgery in 2023 she had struggled to mobilise and her symptoms had not improved as expected. Our adviser explained that where surgery has been carried out without the impact hoped for, it is appropriate to consider the less invasive treatments set out in the Guidelines, rather than opt for further surgery.

22. We have not seen that this impacted Mrs S’s ability to access appropriate care. This is because the Trust advised Mrs S it did not think surgery was appropriate to treat her symptoms and made a referral to the Pain Management Team. This was the appropriate course of action and is in line with Guidelines.

Letter from Senior Spinal Fellow

23. Mrs S felt the letter written by the SSF did not record everything they said to her in the consultation in February 2024, and as a result it was too vague and did not reflect accurately her condition.

24. Mrs S told us she thinks this prevented her from accessing reasonable adjustments at work and certain benefits such as a blue badge. She also told us she felt it meant people did not believe the symptoms she was reporting.

25. The clinical letter is addressed to Mrs S’s GP, and our adviser explained it was written to an expected standard and was not intended for an employer. It would not have been appropriate for the SSF to comment on long term sickness or the requirement for certain benefits in this letter and it is not part of clinical duty to do so. The Department for Work and Pensions, the department responsible for state benefits, does not always require reports from medical professionals but where it does it requests these specifically (DWP Medical (factual) reports: A guide to completion - GOV.UK.

26. Mrs S told us the letter did not refer to the problems she was having in her neck. The letter gives information about the “cervical vertebrae”. The cervical vertebrae are seven bones located in the neck region of the spine. Although the language in the letter could have been clearer, the letter refers to the neck and Mrs S’s related symptoms. The letter states Mrs S is experiencing neck pain and there are degenerative changes (age related wear and tear) in the cervical spine but nothing compressive (nothing pressing on the nerves or spinal cord). We consider the letter was appropriate for the intended audience which was Mrs S’s GP.

27. Taking all this into account, we saw no indications of failings for this part of the complaint.

Attempted re-referral from GP to the spinal team

28. Mrs S explains after experiencing a fall and new symptoms of pain in her pelvis in July 2024, she visited her GP who tried to refer her back to the Trust by calling the SSF directly. Her GP recorded in Mrs S’s medical notes that the SSF refused the referral.

29. The Trust said the SSF does not remember or have any record of this call. The Trust stated it called Mrs S’s GP Practice to enquire about this call and the GP Practice advised the Trust it had no record of this call. Mrs S disputed this and advised the Trust she has evidence of this call on her NHS app. The Trust responded to her to reiterate that the SSF states they did not receive this call and has no note of it.

30. We looked at emails between the Trust and GP Practice and Mrs S’s medical records. The GP Practice told the Trust of a letter on Mrs S’s medical records documenting a discussion with the Trust in August 2024. There is an entry on Mrs S’s medical records documenting a phone call with the SSF in August 2024. We are persuaded a phone call did take place between the GP and SSF in August 2024 and the GP sent a follow up letter to the Trust. We have brought this to the attention of the Trust, and we are satisfied this action appropriately acknowledges the call from August 2024.

31. We understand it was distressing for Mrs S to hear the SSF had no memory of the call and this led her to distrust information from the Trust. We believe the Trust’s record keeping could have been better and its communication about the phone call could have been more transparent. Despite this, we have not seen indications this affected Mrs S’s care.

32. From medical records and an account from Mrs S’s daughter, we can see during the appointment with the SSF in February 2024, they explained to Mrs S her symptoms would most likely not be helped with further surgery and may make her symptoms worse. This is in line with the Guidelines which list less invasive treatments before surgical intervention.

33. Our adviser explained spinal surgery is only mandatory in two circumstances: Cauda Equina Syndrome (compression of the nerves at the base of the spinal cord) or if spinal tumours are present. This is because these conditions can lead to severe and permanent symptoms. Symptoms that indicate surgery is mandatory include losing control of the bowels or legs. Mrs S did not have these symptoms but reported numbness in her right leg, headaches, pain in her left arm and shoulder and in her neck.

34. Spinal surgery is not always appropriate to treat pain and is not done to treat numbness, tingling or neck pain. The Trust carried out shoulder, head and full spinal MRIs and physical examinations of Mrs S to investigate her symptoms and made a referral to a Pain Management Team when it was determined surgery would not be suitable. In response to Mrs S’s complaint, the Trust held a MDT meeting in November 2024 where it was agreed unanimously surgery would not be appropriate. Our adviser said this was appropriate as an MDT considers different options and opinions.

35. Mrs S told us she had private spine and shoulder MRIs in June 2024. Our adviser told us there are some minor differences between the MRI results from the NHS and those done privately. They told us results from both the NHS and private scans do not show significant nerve compression changes and do not indicate surgery would be mandatory. They explained MRI’s are only a guide and do not determine by themselves if surgery is appropriate.

36. We consider the Trust’s decision not to operate further and refer Mrs S to pain management was appropriate and in line with the Guidelines. We have seen indications communication broke down between Mrs S and the Trust and this led to a misunderstanding about why the referral was refused.

37. Taking all this into account, we saw no indications of failings for this part of the complaint.

38. We thank Mrs S for taking the time in bringing her complaint to our attention. We hope our explanation brings some reassurance that Mrs S’s care and treatment was not impacted by the events following the consultation with a SSF in February 2024.

1. We have carefully considered Mrs S’s complaint about Royal Devon University Healthcare NHS Foundation Trust (the Trust). We have seen no indication that anything went seriously wrong. We have decided we cannot link the events complained about to the impacts Mrs S has described.

2. We would like to reassure Mrs S we have not seen indications Trust staff missed an opportunity to treat her symptoms. Additionally, it appears it made appropriate decisions about her treatment plan and took her symptoms into account when deciding not to treat her surgically. We hope our explanation below goes some way to provide Mrs S some closure for her concerns.