The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

3. Mrs T complains about the treatment she received from the Trust prior to and after spinal surgery on 15 October 2024. She says the Trust did not appropriately assess her risk of blood clot, failing to consider her age and the prone position used during surgery.

4. She also says the Trust failed to give her heparin after the spinal surgery and inappropriately discharged the next day, 16 October 2024, as she was placed on early mobilisation.

5. Mrs T says the Trust’s failings led to her suffering a pulmonary embolism and having to go trough a thrombolysis which placed a large clot on her spine. She says she required a second surgery to remove the clot, which left her paralysed and caused her double incontinence (loss of control over both her bladder and her bowels). She also says she has been having nightmares, and her life and mental health are severely affected.

6. As an outcome of her complaint, Mrs T would like an apology from the Trust, acknowledgement they could have done better and a financial remedy.

7. Mrs T had pains down her legs and issues with her bladder. She visited the hospital and was diagnosed with a L4-5 stenosis with bilateral claudication (a narrowing in her lower back which is pressing on nerves on both sides and causes leg pain or weakness when walking or standing).

8. The Trust advised her the pain could be managed through spinal surgery (decompression of the spine), but surgery would not help with the bladder. Mrs T accepted to go through the surgery.

9. Mrs T had surgery on 15 October 2024. The Trust discharged Mrs T on 16 October 2024.

10. On 24 October 2024 Mrs T had a clot removal surgery (hematoma).

11. The clot removal surgery resulted in paralysis from the waist down. She regained the ability to walk but her mobility remains limited.

Assessing her risk of blood clot

15. Mrs T complains the Trust did not properly assess her risk of blood clot. She says they failed to consider her age and the prone position used during her surgery. She complains about the Trust not administering the anticoagulant heparin to her after the surgery. She also complains about the Trust’s decision to place her on early mobilisation and discharging her the next day after her surgery. She says all these caused her to develop a pulmonary embolism.

16. On 5 July 2024 she had a meeting with the Trust to discuss the risks of the surgery. At this meeting the Trust explained to her the risks included infection, bleeding, haematoma formation (blood build up outside a blood vessel), cerebrospinal fluid leakage, injury to the root causing paralysis, failure to improve, worsening symptoms, adjacent segment disease, the need for revision surgery, deep vein thrombosis/ pulmonary embolism, recurrence of stenosis, pre operative MI/stroke, anaesthesia risks and prone related problems.

17. The Trust also assessed Mrs T’s risk of blood clots (VTE). It completed the Risk Assessment for Venous Thrombosis form.

18. The Trust assessed her as low risk and planned to manage the risks through early mobilisation and the use of a foot pump. Mrs T consented to the surgery and signed the consent form.

19. Mrs T had surgery on 15 October 2024. The records show the Trust managed her risk of blood clots by using foot pumps and early mobilisation.

20. The Trust discharged Mrs T on 16 October 2024, advising her to avoid bending, lifting weights and twisting for 6 weeks, and to avoid sitting in the same position for more than 20 minutes at a time. Following her discharge, she had a three-hour journey home.

21. On 24 October 2024 Mrs T had a clot removal surgery (hematoma). After the surgery she spent about 5 weeks in hospital. During her stay, the hospital gave her injections of heparin into her stomach to prevent blood clots.

22. In their complaint response the Trust stated it discussed the risks and complications of spinal surgery with Mrs T prior to her surgery. It said it agreed a plan with Mrs T to manage her low risk of deep vein thrombosis or pulmonary embolism. It said the use of foot pumps and early mobilisation would be sufficient.

23. The BASS guidance lists the risks of spinal surgery as damage to nerve root, recurrent leg pain, problems with positioning during the operation, infection, bleeding, and blood clots (thromboses) in the deep veins of the legs (DVT) or lungs (pulmonary embolism), damage to the cauda equina and paralysis, stroke, heart attack and rarely death.

24. The NICE VTE says patients should be assessed to identify the risk of VTE and bleeding and recommends the use of the Department of Health VTE risk assessment tool.

25. It also says when someone is admitted for planned spinal surgery, they should be given mechanical VTE prevention right away. This should be done either by using anti-embolism stockings or Intermittent pneumatic compression (IPC).

26. IPC is a mechanical device used to prevent blood clots (VTE) by gently squeezing the legs or feet in cycles. Foot pumps are a type of the IPC device which provides compression in a patient’s foot to improve blood flow.

27. We can see the Trust explained all the known risks of the spinal surgery and records show the risks explained to her were those listed in BASS.

28. From the medical records, we can see the Trust’s VTE assessment form is a replica of the Department of Health’s VTE risk assessment tool. Our adviser told us the Trust took the appropriate actions in assessing Mrs T’s risk of VTE.

29. After identifying her as low risk of VTE the Trust acted in line with NICE VTE guidelines by managing the risk using a foot pump. For this reason, we will not be taking any further action.

30. We appreciate it has been distressing for Mrs T to have a VTE following her surgery and for her to be concerned she wasn’t assessed appropriately. We hope she finds it reassuring we have not seen any indications of failings in the Trust’s actions.

Not administering heparin

31. Mrs T complains the Trust failed to administer her heparin after her spinal surgery.

32. Heparin is an anticoagulant which is used to prevent blood clots or keep existing clots from getting worse.

33. NICE VTE guidance states heparin (LMWH) should only be considered for elective spinal surgery patients when their risk of blood clots is higher than their risk of bleeding, particularly in major or complex procedures. If LMWH is used, it should begin 24 - 48 hours after surgery and continue for 30 days or until the patient is mobile or discharged.

34. Our adviser told us in clinical practice most spinal surgery patients go home the day after surgery, so extended LMWH is not commonly required unless their risk of VTE is high.

35. Mrs T was assessed as low risk for VTE, meaning the likelihood of a clot was judged to be lower than the potential harm of bleeding. Based on this assessment, the Trust followed the VTE guidance by managing her risk with early mobilisation and the foot pump.

36. Offering LMWH during surgery or within the first 24 hours would have gone against the VTE guidance. Anticoagulation too early after spinal surgery increases the risk of serious bleeding complications. We see no indications of failing in the Trust not administering Mrs T heparin after the surgery and hope this provides her with reassurance.

Early mobilisation

37. Mrs T complains she was mobilised too early following her surgery.

38. Early mobilisation involves getting a person up and moving as soon as it is safe after surgery. This movement helps prevent VTE by keeping the blood flowing in the legs, which reduces the chance of blood clots forming. Patients who are not mobilised early after surgery have a higher risk of experiencing blood clots.

39. There is no formal guidelines on early mobilisation, however it is known to be a safe clinical practice.

40. BASS 2021 explains after surgery, some back and leg discomfort is expected, and the medical team will help manage this with appropriate pain relief.

41. It goes on to say, a major focus of recovery is getting moving early. Once patients are independently mobile and stable, they can usually go home within one to two days.

42. BASS 2021 says patients who have undergone spinal surgery are typically discharged the following day or within two days.

43. We can see the Trust supported Mrs T by ensuring she was mobilised safely after her surgery. Aside from foot pumps it also used early mobilisation to manage the risk of Mrs T having blood clots. This shows they took her risk seriously and acted in line with guidance by applying preventative measures.

44. We recognise Mrs T concerns about the care she received from the Trust. We understand how worrying Mrs T situation must have been when she suffered the pulmonary embolism. We hope our review will reassure her that she received care which was in line with guidelines.

1. We have carefully considered Mrs T’s complaint about The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (the Trust). We were sorry to hear how Mrs T has been affected. It is clear she had a difficult and upsetting experience, and understandably, Mrs T wants to ensure this does not happen again.

2. We have decided not to consider Mrs T’s complaint any further as we have seen the Trust acted in line with guidance in the care it provided her.