12. 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 we consider it was appropriate for the surgeon to administer the nerve block. We cannot robustly say that the anaesthetist explicitly told her the injection would be a ‘nerve block’, but given Miss D’s limited alternative options for effective pain management, it is not possible to determine whether she would have declined the nerve block or not.
13. The first thing to note is that Miss D’s concerns stem from being told she could not have an epidural after having spinal surgery in the past. She believes this means the nerve block should never have been given. However, a femoral nerve block is not the same as an epidural. She was not, therefore, given this against the advice of her spinal surgeon. We hope this provides her with some clarity on the difference between the two procedures.
14. Our clinical adviser explained that Miss D’s medical records did not indicate issues with peripheral nerves, weakness or numbness or any overlying infection at the nerve block site, which would make a nerve block unsuitable for her. They also confirmed having a history with your spine, as Miss D explains she has, does not prevent you from having a nerve block. We acknowledge her concern that the nerve block has caused her ongoing issues. That does not, however, mean it was wrong to give it to her and we hope this provides her with some reassurance that there was no reason she should have been considered unsuitable to have it.
15. Notwithstanding this, we looked at whether communication about the block was adequate.
16. Miss D tells us that on the day of her surgery, she had two discussions with the anaesthetist; one in the morning and another immediately prior to surgery. On both occasions, she says she was told she would receive a general anaesthetic and an injection for pain relief, which she did not understand to be a nerve block. Miss D states she did decline to have an epidural during the consultation with the anaesthetist. She states she would not have consented to a nerve block, due to her previous spinal surgery and her fear of paralysis.
17. In its complaint response the Trust explained that the femoral nerve block was administered to Miss D as a standard accompaniment to the general anaesthesia. It said it was discussed with Miss D on the morning of her surgery and prior to her entering surgery as part of the pre-theatre safety checks. It explained that proceeding without a nerve block may have led to a very high failure rate of post operative pain control and would have been excruciatingly painful for Miss D.
18. Our adviser referred us to Association of Anaesthetists of Great Britain and Ireland. AAGBII: Consent for Anaesthesia 2017. The guidance states that anaesthetic can be considered a component of another treatment and that a separate consent form signed by the patient is not required. This means there was no need for the surgeon or anaesthetist to ask Miss D to sign a separate consent form.
19. The guidance also states that anaesthesia and its risks should be explained to patients as early as possible, ideally before admission for elective surgery, with the anaesthetist responsible ensuring understanding. The information should reflect what the patient considers relevant, and patients should have an opportunity to ask questions. Anaesthetists should record the discussion.
20. Our adviser explained that, in line with the applicable guidance, the anaesthetist should discuss all aspects of proposed anaesthetic with the patient, including the risks and benefits of each element. In Miss D’s case, that means the general anaesthetic and the femoral nerve block. They told us that this discussion should take place on the day of surgery, typically in the morning for morning surgery, as was the case with Miss D.
21. The records show a discussion in the morning was had and that the risk of nerve damage and numbness was mentioned. The conversation was documented, but not word-for-word. And we would not expect it to be – it is usual for clinicians to record a summary of the key things spoken about. This means we cannot know exactly what was said. But on balance, we are satisfied that the anaesthetist did tell Miss D she would have a pain-killing or anaesthetic injection whilst under general anaesthesia and that there were risks and benefits to that. This was in line with the guidance.
22. That said, we recognise that Miss D said she did not understand the terminology used by the anaesthetist to mean a nerve block. As we have already set out, the anaesthetist should have ensured she understood what was planned, and we think overall they did. They may not have used the term ‘nerve block’ but they described the procedure.
23. We understand that Miss D says she would not have agreed to it had she known it was a nerve block, but on balance, for the reasons we go on to explain, we cannot say either way what she would have decided.
24. We have already explained that there was no good reason that Miss D was not suitable to have a nerve block. Her concerns appear to be rooted in a misunderstanding. It is more likely than not that had this come up during the discussion, the anaesthetist would have been able to provide her with the necessary reassurance that it was fine for her to have the block.
25. Moreover, as the Trust explained in its response, Miss D needed the block for appropriate post-operative pain control, as she had no reasonable alternative. Our adviser explained that these blocks are known to offer significant advantages to patients having a total knee replacement, as Miss D did. She was likely not suitable for opiates, which, our adviser explained can be given along with a general anaesthetic for knee surgery. Without opiates or a nerve block, Miss D would have suffered excruciating pain after the operation and in turn risked the procedure failing.
26. We think that had the surgeon and/or anaesthetist been told she did not want a nerve block, they would most likely have explained this to her, reassuring her that it was in her best interest. We cannot say, even on the balance of probabilities, whether, having heard this reassurance, Miss D would have decided to go ahead without the nerve block. She says she would have, but we have to take into consideration that this is with the benefit of hindsight, having suffered ongoing issues following the procedure. It is difficult to robustly and fairly conclude that being told there was no good reason not to have it, and that not having it would be horrendously painful, Miss D would have declined to have it.
27. We are sorry to hear that Miss D continues to experience ongoing difficulties following her knee operation. We recognise how distressing this must be for her. We hope our explanation provides some reassurance that the nerve block was an appropriate and reasonable option for her at the time.