Surgery in March 2022
23. 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 something has gone wrong.
24. Miss O complains the surgeon at Trust A failed to correctly perform her septorhinoplasty surgery in March 2022. She told us she believes they should have inserted a graft (a piece of material used to shape or reinforce the nose) to support her nose internally.
25. Miss O’s clinical records from Trust A include a signed patient consent form for revision septorhinoplasty (open), dated 11 March 2022. The records also include surgery records for this procedure on the same day. We explain what this procedure is in more detail in paragraph 30.
26. Section two of the consent form relates to ‘serious and frequently occurring risks’. The risks recorded on Miss O’s consent form are bleeding, pain, infection, GA (general anaesthetic), inadequate improvement, septal perforation (a hole in the nasal wall), collapse (also known as saddle deformity - a flatten/dip in the middle of the nose) and a scar.
27. We asked our ENT clinical adviser if Trust A performed Miss O’s surgery in March 2022 in line with relevant standards or guidelines.
28. Our advisor explained there are no specific guidelines to say how surgeons should perform a revision septorhinoplasty and whether they should insert a graft. Therefore, surgeons should use their clinical judgement, following a discussion with the patient, to determine what technique would achieve the best result and outcome for the patient.
29. Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. Therefore, in this situation, we will use the professional judgement of our ENT clinical adviser which is based on established GMC’s good medical practice and RCS’s good surgical practice.
30. Our ENT clinical adviser explained septorhinoplasty is a type of nose surgery which allows correction of nasal airway obstruction, adjustment of the nasal shape and correction of any external deformity. Our adviser said surgeons can perform the rhinoplasty part of this surgery by an open or closed technique. Our adviser explained the open technique is typically recommended for correction of more difficult deformities and many ENT surgeons who perform septorhinoplasty surgery favour this method.
31. Our adviser noted the surgery records are comprehensive, complete and of a good standard, in line with GMC’s good medical practice. Our adviser explained the consent process prior to the nasal surgery in March 2022 was of a reasonable standard. The procedure matches the surgery that was performed and covers all the main risks and complications.
32. Our adviser explained surgeons use grafts for saddle deformity to build up any dip. Our adviser said surgeons would not insert a graft if there were no saddle deformity present. Our adviser noted no evidence in Trust A’s records, to suggest Miss O had a saddle deformity prior to her open septorhinoplasty surgery in March 2022.
33. We are very sorry to hear Miss O is unhappy with the appearance of her nose following her septorhinoplasty surgery in March 2022. We do not underestimate the emotional impact the appearance of her nose has on her.
34. We must base our decisions on evidence, relevant standards and good practice. In doing this, we cannot see any indications something went wrong when Trust A did not insert a graft during Miss O’s surgery in March 2022.
35. We know from our advice, there are no standards or guidance to say Trust A should have inserted a nasal graft in March 2022. We recognise any decisions to do this are based on clinical judgement.
36. Our adviser explained to us that surgeons use grafts when a saddle deformity is present. As there is no evidence of Miss O having a saddle deformity, prior to her surgery in March 2022, we cannot say Trust A did something wrong by not inserting a graft during the surgery in March 2022. Therefore, we will not be taking any further action on this part of her complaint.
Trust A’s decision not to perform a further nose surgery
37. Following her revision septorhinoplasty surgery in March 2022, Miss O had six follow-up appointments with the ENT clinic at Trust A between March 2022 and December 2023.
38. In the clinic letter from May 2022, the first consultant said Miss O’s nose would likely become slimmer as the swelling reduces and scar tissues contract. They explained this can take nine to ten months. The consultant recommended Miss O’s GP refer her for counselling and agreed to re-visit Miss O’s concerns again if she remained unhappy after counselling and the required healing time had passed.
39. Miss O completed counselling in September 2022. We can see from Trust A’s records she attended Trust A again in August 2023, following a referral from her GP, as she remained unhappy with her nose.
40. In the clinic letter from this appointment, the consultant declined to carry out a further surgery on Miss O’s nose, as they did not feel they could achieve Miss O’s expectations. The consultant referred Miss O to another consultant for a second opinion.
41. In the clinic letter from September 2023, the second consultant said it was their professional opinion that Miss O should not have a further revision surgery, due to high chances of severe complications. In the letter, the consultant said despite explaining their concerns to Miss O, she insisted on going ahead with a further surgery. Therefore, they agreed to see Miss O again in three months to re-review the situation, following allergy testing results.
42. In the clinic letter from 5 December 2023 the second consultant said Miss O had told them she had lost trust in the department. Because of this, the second consultant said they considered further surgeries carried out by the department may lead to further unhappiness. Therefore, they were happy to refer her care to another Trust.
43. In this letter, the second consultant also explained if Miss O requires a further surgery, it would be an augmentation septorhinoplasty (a nose surgery designed to enhance the shape and structure by adding tissue or implants). The consultant said they had submitted a funding application for this, as a cosmetic procedure and if the committee approved this, they can re-consider.
44. In the clinic letter from 13 March 2024, the second consultant at Trust A said following a long and emotional discussion with Miss O, she requested a second opinion from a rhinologist at another Trust. Therefore, the consultant referred Miss O to Trust B for a second opinion.
45. In its complaint response dated 22 April 2024, Trust A say it made the decision to refer Miss O’s care to Trust as she had told the second consultant she had lost faith in the care Trust A had provided her. It said because it referred Miss O to Trust B, decisions about further care, treatment and funding requests must be actioned by Trust B.
46. We asked our clinical adviser if Trust A’s decisions to not perform a further nose surgery were in line with policies, standards or guidance.
47. Our adviser explained a consultant should reach a decision to recommend or proceed with revision nasal surgery after full assessment of the patient, the nasal problems and the likelihood of a successful outcome.
48. Our adviser said the operating surgeon would need to be confident there was a reasonable chance of success if they decided to perform the surgery. If there is a substantial risk of not improving the problems of a patient's nose sufficiently, a surgeon may consider the risk of surgery is too high. In these circumstances, the surgeon should consider a second opinion from a colleague with expertise in this form of surgery.
49. We recognise from what Miss O has told us, Trust A’s decision not to perform a further surgery caused her distress and disappointment, which we are sorry to hear.
50. The Trust told us that it does not have a specific policy which sets out eligibility criteria for revision nasal surgery. It explained clinicians make these decisions using their professional clinical judgement.
51. From our advice, we know surgeons should use their clinical judgment, taking into account a patient’s individual circumstances, any potential risks and benefits and the likelihood of achieving a successful outcome.
52. The GMC’s standards on good medical practice states clinicians should work within the limits of their competence. It also states clinicians should listen and respond to a patient’s questions and take into account their views. It also states clinicians should refer a patient to another practitioner when this serves the patient’s needs.
53. The RCS standards on good surgical practice says clinicians should work with colleagues in the ways that best serve patients’ interests.
54. The clinic letters clearly document Miss O’s concerns and the first and second consultants’ clinical judgements. We consider this demonstrates both the first and second consultant listened to Miss O’s concerns over multiple appointments and considered her preferences when weighing up the risk and benefits of further surgery.
55. When the first consultant was not confident they could achieve Miss O’s desired expectations, they arranged a referral to another clinician for a second opinion. Based on our advice and the standards, we consider this to be in line with the GMC and RCS standards mentioned above.
56. The second consultant used their clinical judgement and considered the risks outweighed Miss O’s reasons for wanting further surgery. They noted and considered her loss of trust in the department and following further discussion with Miss O, referred her to Trust B for another opinion.
57. From our advice and available standards, we consider this to be appropriate and reasonable. We consider Trust A were acting in Miss O’s bests interests, due to breakdown in relationship with the department.
58. For these reasons, we cannot see any indications of a failing in Trust’s A’s decisions not to perform a further nose surgery. Therefore, we will not be considering this part of Miss O’s complaint further.
Trust B’s decision not to perform a further nose surgery
59. Miss O complains Trust B failed to agree to carry out a further surgery on her nose in June 2025.
60. In Trust B’s complaint response, it said it considered Miss O’s previous surgery at Trust A was successful in achieving its aim of providing a good nasal airway. It acknowledged Miss O’s unhappiness with the appearance of her nose. Trust B explained its policy states it can only provide nasal surgery solely for functional improvement, not cosmetic.
61. Our adviser explained that generally, the NHS does not cover cosmetic only nose surgery. They explained that functional nose surgery, which may include a cosmetic component is generally considered reasonable and acceptable. Our adviser explained the requirement for funding applications for this surgery is variable within the UK, but normal practice in some regions.
62. We reviewed Trust B’s policy for non-cosmetic nasal surgery for all ages. The policy states the criteria for rhinoplasty/ septorhinoplasty is based on the signs and symptoms of medical issues only (i.e. improving an obstructed nasal airway). It says Leicester, Leicestershire and Rutland Integrated Care Board (LLR ICB) does not commission rhinoplasty/septorhinoplasty for cosmetic reasons.
63. We appreciate Miss O wanted Trust B to agree to a further surgery. We understand from what she has told us, when it did not, she felt significant distress and disappointment.
64. We understand Trust B’s assessment and testing of Miss O’s nose concluded there is no functional issues. Therefore, it could not meet its eligibility criteria of a functional need. Trust B’s policy states funding will not be routinely provided for revision surgery to improve the appearance or because a patient is unhappy with the outcome of a previous surgery.
65. Given Miss O’s issue is non-functional, we consider Trust B has followed its own policy and see no indications something went wrong. Therefore, we will not be considering this part of the complaint further.
66. We would like to thank Miss O for bringing her complaint to us. We understand she may be disappointed in our decision. We do hope this statement explains our decision and the careful work we have done to look into her complaint.