Leeds Community Healthcare NHS Trust

8. Mr O complains that ​the Trust’s musculoskeletal department (MSK) in 2022 failed to provide:

• an MRI to check the soft tissue of his back • an effective treatment or advice for management of his pain between 22 October 2022 to 5 June 2023.

9. Mr O states he remains in severe pain and, because he does not know how to manage his condition, he is unable to seek suitable work causing him hardship.

10. Mr O is seeking an acknowledgment of the impact of the failure to treat his condition correctly.

11. Mr O suffered an injury to his back and was referred by his GP to the Trust’s MSK service on 30 June 2019. He states he had to resign from his work in part due to pain in November 2021.

Evidence we considered

12. In reaching these views we have considered the following evidence:

• Mr O’s complaint to PHSO and related documentation • Email contact from Mr O • Relevant patient records, image report, and complaint file from the Trust • Images and image reports from Leeds Teaching Hospitals NHS Trust

13. We have also obtained clinical advice from an independent physiotherapist (our adviser). We consider they have the relevant experience and expertise to provide advice on this case and they do not have a conflict of interest.

14. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. We have referred to the following standards:

• National Institute for Health and Care Excellence (NICE), NG59, Low back pain and sciatica in over 16s: assessment and management, 2016 • United Kingdom Spine Societies Board (UKSSB), National Low Back and Radicular Pain Pathway, 2017 • General Medical Council (GMC), Good Medical Practice, 2013 • Leeds Community Healthcare NHS Trust, Clinical Imaging Requests from Non-Medically Qualified Registered Healthcare Professionals Policy, 2023 • NHS Complaint Standards, 2022 • PHSO’s Severity of Injustice scale

Failure to perform an MRI

15. Mr O says, following his referral to the MSK department at the Trust on 22 February and 13 December 2022, Trust staff refused to perform an MRI (magnetic resonance imaging scan) despite his repeatedly asking for this. He further states the referrals made by his GP included requests for an MRI to be performed.

16. The Trust says the referrals sent by Mr O’s GP gave information about his symptoms with a request for further assessment and advice. It states no correspondence, recommendation or request for an MRI scan was received by the MSK service.

17. The records provided by Mr O’s GP support this assertion, showing no request for an MRI on the referral forms, and the GP letter of 15 February 2024 specifically states the GP does not request specific tests as they prefer to leave such decisions to the MSK team.

18. The Trust states the spinal advanced physiotherapy practitioner (APP) who assessed Mr O advised an MRI scan provides an accurate picture of spinal anatomy at the time taken. In the absence of any red flag symptoms or neurological symptoms (such as loss of power in the limbs) it is not indicated as it will not change the management. An MRI scan will not be able to give a prognosis of what pain symptoms Mr O may get in the future and was not necessary in Mr O’s case.

19. NG59, section 1.1.6 states clinicians should, ‘Consider imaging in specialist settings of care (for example, a musculoskeletal interface clinic or hospital) for people with low back pain with or without sciatica only if the result is likely to change management.’

20. Our adviser informs us the records indicate between 22 February and 25 October 2022 the treatment and advice for Mr O’s back pain was appropriate and in line with NG59. It is also in line with the Trust Clinical Imaging Requests from Non-Medically Qualified Registered Healthcare Professionals Policy, which states prior to referring someone for an investigation the professional should make sure there is a clear reason for the investigation, and it would positively influence the management of care.

21. Our adviser said Mr O’s reported symptoms, and the assessments performed at all the physiotherapy appointments did not show any indications an MRI of his spine was recommended.

22. GMC Good Medical Practice, section 7, states clinicians must adequately assess a patient’s condition(s), taking account of their history, including symptoms and carrying out a physical examination where necessary.

23. Trust records indicate Mr O’s assessment included his reported symptoms, pain level and stated concerns. It also included physical assessments including his range of motion. It is our decision these assessments were in line with GMC Good Medical Practice.

24. Our adviser informs us the records do not indicate any evidence of red flag symptoms such as progressive or severe neurological deficit, or persistent radicular pain (sciatica) that has not responded to conservative management and where imaging would inform further treatment decisions.

25. Therefore, an MRI would not have been expected to alter the management plan or improve clinical outcomes.

26. They further advise us that the supporting evidence cited in NG59 highlights that imaging in such cases does not improve pain or function, and may instead lead to unnecessary interventions, increased patient anxiety, and inappropriate referrals.

27. We acknowledge Mr O’s feelings on this issue, and his belief an MRI would have helped him gain clarity of treatment going forward. We have not seen there was a requirement for an MRI. We can find no indication the lack of imaging adversely affected Mr O’s condition or pain management.

Treatment and advice for management of pain

28. Mr O states the Trust failed to provide him with an effective treatment, or advice, for the management of his pain, between 25 October 2022 and 5 June 2023.

29. The Trust said NICE guidelines recommend people with low back pain should be encouraged to continue with normal activities, it also recommends exercise. It says this is why the physiotherapists seen by Mr O recommended this approach.

30. NG59, section 1.2.1 states, staff should:

‘Provide people with advice and information, tailored to their needs and capabilities, to help them self-manage their low back pain with or without sciatica, at all steps of the treatment pathway. Include: 31. information on the nature of low back pain and sciatica 32. encouragement to continue with normal activities’

33. Mr O’s records do not show any evidence he presented with complex or widespread pain, as his pain was limited in the area it affected. He was provided with home exercise information in June 2022 and in June 2023. He was signposted to the ‘Active Leeds’ directory of activities in the Trust area to support him with improving mobility and using movement to manage his conditions. These actions were in line with NG59.

34. The National Low Back and Radicular Pain Pathway and NICE guideline NG59 recommend physiotherapists complete an assessment of how a patient’s symptoms affect their work and daily function, promote early return to work, and advise on modified duties and graded return plans. They may also issue fit notes, and refer to occupational health services. We can find no evidence this was done at any point between 22 October 2022 and 5 June 2023.

35. At the consultation on 15 March 2023 the records indicate the treatment plan was to refer Mr O to a Spinal Advanced Physiotherapy Practitioner (APP) for further examination and assessment. Mr O saw the APP on 12 April 2023 and records indicate an X-ray was agreed. During this consultation a conversation about the fact the X-ray may prove to be normal, and he may have degenerative changes, is noted. It is recorded Mr O accepted this. It is also noted an MRI was discussed and the APP advised the need for this was not indicated as Mr O had no current leg symptoms.

36. The records show the X-ray was performed on 2 June 2023 and Mr O was informed of the result the same day. The X-ray did not show any structural changes or abnormalities. Mr O was signposted to the ‘Active Leeds’, an initiative that supports people in the Trust’s area to become active and was discharged from the MSK department.

37. NG59, section 1.2.14, states consideration should be given to a combined physical and psychological programme if previous treatment has been unsuccessful.

38. Mr O’s records indicate he still had persistent pain and was worried about the kind of work he could do. Therefore, our adviser said he met the entry criteria for the Comprehensive Combined Physical and Psychological Programme (CPPP).

39. The CPPP includes: • Persistent low back pain with significant impact on function • Psychosocial obstacles to recovery (e.g. work-related concerns) • Insufficient improvement following core therapies

40. Our advisor informs us, in line with the National Low Back and Radicular Pain Pathway, and NG59, a more appropriate approach, would have included the following:

• Specialist Triage Review to reassess Mr O’s progress and determine the next step in care.

• Referral to a CPPP which is a structured, multidisciplinary programme incorporating physical rehab, cognitive behavioural therapy (CBT) principles, goal setting and return-to-work planning. (NG59 recommends this for people with persistent low back pain and significant psychosocial barriers to recovery)

• Clear Self-Management Support, Including education, reassurance, and tools like The Back Book. NG59 emphasizes empowering patients to manage their condition through activity, pacing, and psychological support.

41. There is no indication in the records provided by Mr O or the Trust this approach was considered, or discussed with, Mr O.

42. We understand how challenging it is to live with back pain and the impact this can have upon a person. We have seen the Trust appropriately advised Mr O to remain active and directed him to a local service. At this time, given his back pain was severe and persistent over a long period of time it is our view the lack of an assessment of how Mr O’s symptoms affected his work and daily function, and lack of advice on modified duties and graded return plans was a failing. This was not in line with NICE guideline NG59 and the UKSSB pathway.

Impact

43. Mr O states he remains in severe pain and, because he does not know how to manage his condition, and he is unable to seek suitable work. He states this means his benefits are affected, causing him hardship and his mental health has been adversely affected. and his benefits are affected, causing him hardship.

44. It is our view the lack of advice given to Mr O, between 22 October 2022 and 5 June 2023, regarding such things as modified duties and graded return plans had a negative effect on Mr O’s physical and mental health.

45. Mr O’s condition involves persistent low back pain which can interfere with physical functions such as sitting, standing, walking, lifting, bending, or twisting for extended periods. These limitations may make physically demanding jobs difficult, although roles that allow flexibility, such as alternating between sitting and standing or taking regular breaks, may still be suitable. It can also affect mental health and social interactions. functional limitations and psychosocial barriers to recovery, can vary depending on individual circumstances.

46. In terms of how it affects people on a daily basis, NICE guideline NG59 indicates many individuals with persistent pain are able to manage by using pacing strategies. This can involve breaking tasks into smaller parts and allowing time for rest, which can help maintain independence. We recognise this is no doubt frustrating for Mr O and may cause him to be fearful of moving, or experience low mood. Had he been provided with further support and assessment of his needs he may have been able to explore other options to manage his symptoms.

47. We acknowledge the ongoing negative effect this can have on his mental health, and ability to function and recover. We cannot say the failings found were the main reason for his continued pain.

1. We partly uphold Mr O’s complaint. We are sorry to hear about the events which led to Mr O’s concerns and appreciate how frustrating and upsetting this has been for him.

2. We have carefully considered Mr O’s complaint about a Leeds Community Healthcare NHS Trust (the Trust). We understand his circumstances have been involved and prolonged. We understand the anxiety and distress this has caused him.

3. It is our view the Trust’s decision there was no requirement for an MRI scan was in line with NICE guidance. We acknowledge Mr O’s feelings on this issue, and his belief an MRI would have helped him gain clarity of treatment going forward. We can find no indication the lack of imaging adversely affected Mr O’s condition or pain management.

4. It is our view the lack of advice given to Mr O, between 22 October 2022 and 5 June 2023, regarding such things as modified duties and graded return plans had a negative effect on Mr O’s physical and mental health, was not in line with guidance and this is a failing. This had a negative impact on Mr O’s mental health.

5. We partly uphold this complaint.

6. We recommend the Trust provide an apology to Mr O for the failings we have identified in this report and the distress caused by these and a financial remedy of £600.

7. We also recommend the Trust conduct a review of the advice and treatment options offered to patients, and provide an action plan of improvements, to Mr O and PHSO.