12 December 2023
26. Mrs O complains on 12 December the Trust did not discuss options other than the surgery or its side effects and did not give her information on what could happen if surgery went wrong. She says she was given a basic information sheet that said she would experience bleeding for two weeks.
27. Mrs O also says there was no further investigations or discussions conducted to advise the best surgery going forward.
28. In responding to the complaint, the Trust said Mrs O was listed for a very urgent HALO procedure due to the issue of being lost in the pathway at no fault of Mrs O. The Trust said a standardised patient information sheet was sent to her explaining the procedure.
29. The Trust also said no conversation with Mrs O took place prior to the procedure due to the many months it would take for an urgent appointment to be arranged when the surgeon would have discussed the procedure in detail with her. It said Mrs O signed the consent form, which is when any risks will have been identified and explained.
30. When we investigate a complaint, we first consider what should have happened. We do this by looking at what the relevant clinical guidelines say. We then consider what did happen, and whether this fell short of the relevant guidance.
31. NICE guidance on how to manage a person with haemorrhoids mentions several different surgical treatments:
• injection of haemorrhoids (can be done in a surgical clinic without anaesthesia) • banding of haemorrhoids • rafaelo treatment – this deliveries radiofrequency energy to the haemorrhoids that causes them to shrink. It can be done without anaesthesia • HALO operation – this is one name for an operation where the haemorrhoids are sutured up inside the rectum and not physically removed • surgical haemorrhoidectomy – involves physically removing the haemorrhoids from the patient
32. Our adviser said the choice of operation depends on a detailed discussion with the patient, explaining the advantages and disadvantages of each approach.
33. GMC guidance says you must give patients the information they want or need to make a decision. This will usually include:
• diagnosis and prognosis • uncertainties about the diagnosis or prognosis, including options for further investigation • options for treating or managing the condition, including the option to take no action • the nature of each option, what would be involved, and the desired outcome • the potential benefits, risk of harm, uncertainties about and likelihood of success of each option, including the option to take no action
34. The clinical records show Mrs O had a diagnosis of external haemorrhoids pedicles with associated skin tags as well as ongoing iron deficient anaemia. Her haemorrhoids were a grade three to four, which means they prolapsed outside the anus. She was on iron medication, had ongoing significant bleeding and all other management of her symptoms had not worked.
35. At the outpatient appointment in June 2022, the clinical records show Mrs O’s diagnosis was discussed and mentions about further investigations (sigmoidoscopy) to evaluate her bowel to make sure there was no other cause of her bleeding.
36. We know the sigmoidoscopy did not happen. Our adviser said as Mrs O recently had a colonoscopy as part of her anaemia investigations a sigmoidoscopy would not be needed. The reason for this is both procedures use the same equipment and analyses the same area of concern; therefore, it had already been checked.
37. The clinical records show the surgeon discussed two options at the outpatient appointment in June. The first option was banding of the haemorrhoids. Our adviser gave their view that this option was unlikely to work due to the large size of the haemorrhoids.
38. The second option was a HALO operation. This is the most common operation as it is considered less painful than a traditional haemorrhoidectomy. Our adviser gave their view that a HALO operation was a good option as other conservative measures such as dietary advice and topical creams had been tried and not improved her symptoms.
39. GMC guidance goes on to say:
• you must listen to patients and encourage an open dialogue about their health, asking questions to allow them to express what matters to them, and responding honestly to their questions • you must make sure the information you give patients is clear, accurate and up to date, and based on the best available evidence • you should check patients’ understanding of the information they have been given and do your best to make sure they have the time and support they need to make informed decisions if they are able to
40. The Trust sent Mrs O a patient information leaflet about the procedure. The leaflet detailed the advantages of the surgery, risks and recovery. Mrs O says she did receive this.
41. On 26 October, Mrs O had a pre-operative assessment. The clinical records suggest a booklet was given at this assessment and that Mrs O was allowed to express her concerns, but no concerns were raised. We recognise Mrs O disputes this and say she was told this would be discussed further with the consultant.
42. On 12 December, the day of the surgery the clinical records show all risks and complications were listed and the consent form signed by Mrs O. Given the delays Mrs O experienced our adviser gave their view that the Trust could have offered her a telephone appointment before surgery to cover off any questions or concerns Mrs O may have had about the surgery.
43. We understand Mrs O experienced a considerable delay in getting an operation and that it was a difficult and stressful period for her. While we recognise her assessment happened 18 months prior to her operation date and that this is not ideal, the evidence suggests options of how best to treat her condition was discussed with her. She also received a patient information leaflet on the procedure that mentions side effects.
44. We acknowledge the Trust could have offered Mrs O a telephone appointment prior to her surgery given the delays she experienced. Even if they did, we are unable to say Mrs O would not have gone ahead with the procedure. Also, Mrs O did sign the consent form on 12 December, which detailed the risks and side effects of surgery. We consider the Trust acted in line with NICE and GMC guidance.
Post-operative information
45. Mrs O complains that following the procedure, no consultant came to see her to explain how the surgery went, and the Trust did not provide any post-operative aftercare information.
46. In responding to the complaint, the Trust said post-operative information is routinely provided by the surgery ward and it is documented that the staff nurse provided verbal and written information. The Trust said having been made aware on 15 December Mrs O was not given any-post operative information or follow-up, the consultant called that day to discuss it with Mrs O.
47. Our adviser said many centres have nurse led discharge and it is not mandated that a surgeon must see every patient prior to discharge. The secondary recovery unit or ward is where patients spend most of their postoperative recovery prior to being ready for discharge. It should be staffed by nurses who are trained and competent in nurse-led discharge for day surgery.
48. British Association of Day Surgery guidance says, ‘patients must have the following information prior to discharge:
• a copy of their discharge letter detailing the procedure they have had and any follow-up arrangements • five-day supply of postoperative medication • details of who to contact if they have any concerns. This should be a dedicated phone line to the day surgery unit within working hours and a senior surgical nurse out of hours
49. The discharge summary says Mrs O was given verbal and written information following surgery and that she did not require a follow-up or medication.
50. In her complaint, Mrs O says when she got home, she had to look online for aftercare information for a HALO operation and spoke with her GP a few days after her procedure as she had concerns. She says her GP signposted her back to the colorectal department.
51. We understand how important it is for patients to see the consultant following a procedure. As Mrs O had a nurse led discharge there was no requirement for a consultant to see her. We recognise how important it is for a patient to receive post-operative information following surgery. Even if the Trust did call Mrs O on 15 December as mentioned in point 46, the clinical records conflict with Mrs O’s account. As there are two conflicting accounts, we are unable to reach a view on whether failings happened or not.
Difficulties contacting the Trust
52. Mrs O complains there was no one for her to speak to following her discharge from surgery when she started experiencing extreme bleeding and pain.
53. In her complaint, Mrs O says she had difficulty accessing the service when she was experiencing severe symptoms. She explains she did eventually get to have a follow-up with the surgeon, but no physical examination was done.
54. In responding to the complaint, the Trust said the inability to contact it was very worrying for Mrs O and it apologised for this. The Trust also said the records show, ‘weak pelvic floor and poor tone’ and that the consultant would not routinely follow-up patients for whom he does not plan further surgical intervention for, and where the pelvic floor status would determine whether further haemorrhoid surgery is safe or advisable.
55. The Trust said it can take three months for a HALO to work and confirmed a full examination was done as part of the surgery; therefore, they did not feel it would benefit for a further examination at the follow-up appointment so soon after surgery.
56. GMC guidance in providing clinical care says you must:
• adequately assess a patient(s) condition(s), taking account of their history including: symptoms, relevant psychological, spiritual, social, economic, and cultural factors, the patients views, needs and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary
57. The clinical records show Mrs O was seen by the surgeon on 22 February 2024, just over two months after the procedure.
58. Our adviser said haemorrhoid operations can be extremely painful and often these symptoms settle down in time. We think the surgeon should have inspected Mrs O even if it were to carry out a basic visual inspection of the area, to exclude any sign of infection, abscess, or fissure and where appropriate to provide her with conservative treatment such as painkillers or ointments. They explained that occasionally a patient may need further investigation or treatment such as an MRI scan of the anal canal or examination under general anaesthetic.
59. We understand it was a worrying and difficult time for Mrs O and that she was experiencing bleeding and pain. We can see the Trust acknowledged the difficulties she experienced in speaking to someone and apologised for this. We consider that once the consultant saw Mrs O, they should have conducted a physical examination. There is no evidence it did this. We therefore consider this to be a failing.
60. We have gone on to consider what impact not conducting a physical check had on Mrs O.
Impact
61. When we identify failings, we need to establish whether we can link it to the impact claimed by Mrs O.
62. Mrs O says had other options been discussed and side effects explained to her she may not have gone through the procedure. She says the procedure left her with constant bleeding and pain for three months and she is in a worse position than prior to surgery. Mrs O says she now has a prolapse, her piles are still there, and her symptoms have not been resolved. She says this has affected her quality of life.
63. Mrs O says a consultant not coming to see her and not being provided post-operative aftercare information left her scared and apprehensive going home as she did not know what to expect or how to best look after herself.
64. Mrs O says not having someone to speak to following her discharge after surgery caused her distress as she found it incredibly difficult to speak to someone and this affected her mental health.
65. Our adviser explained if a visual inspection had been carried out on 22 February it would have provided assurances to Mrs O. An anal inspection would also have helped the surgeon decided the nature of the ongoing symptoms and if there were visible external haemorrhoids or if she had developed a tear in the anal lining at the anal verge (acute anal fissure).
66. We can see from the clinical records Mrs O attended accident and emergency (A&E) on 11 March as she was in significant pain and had ongoing bleeding. A visible inspection was carried out and haemorrhoids were still visible.
67. On 20 March, the clinical records show Mr O had a gynaecology review. The records show she was still getting a lot of problems from her back passage and rectal bleeding from time to time, and it was very painful when she had to open her bowls.
68. On examination the clinical records say Mrs O had a lot of skin tags and some piles around the back passage and would be writing to the colorectal surgeon for a review.
69. On 4 April, Mrs O’s GP did a referral to the colorectal surgeon. The clinical records say on examination piles and a small fissure were seen and the anal area was inflamed. Had the colorectal surgeon examined Mrs O he may have seen a small fissure and then started treatment of diltiazem ointment.
70. On 24 April, Mrs O was seen at the surgical ambulatory clinic. She had spasm of the anus and generalised tenderness through the rectum. She had some prolapsing haemorrhoid tissue. Mrs O was prescribed 1mg of amitriptyline (this is an antidepressant used for various types of pain, including neuropathic pain), movicol and diltiazem ointment. The clinical records also say it would be very painful to do a HALO procedure again as the previous procedure has exacerbated the pain. The plan was to treat Mrs O’s symptoms conservatively to allow things to settle down.
71. On 11 July, the clinical records suggest Mrs O’s symptoms had improved with conservative management of her symptoms and that diltiazem has helped and that they recommended she continue with physiotherapy.
72. Considering the above evidence and the clinical advice we received, we can see Mrs O experienced ongoing bleeding and pain. Had a visual inspection been done on 22 February, we consider treatment such as diltiazem could have been given sooner than it was. We can see once this was prescribed on 24 April her symptoms did improve. We consider a visual inspection would have also provided Mrs O with some reassurances.
73. We have gone on to consider whether we should recommend actions for the Trust to put this right.