Northern Care Alliance NHS Foundation Trust

5. Mr N complains about the service he received from the Trust’s spinal and neurosurgery teams from September 2023 to October 2024. He states:

• in November 2023, staff incorrectly removed him from its neurosurgery list, despite him confirming by email in September he still wanted an appointment • on 8 March 2024, he visited the A&E department with severe back pain and his MRI and ultrasound showed he had many issues with his spine - Trust staff did not treat him with the appropriate urgency following his scan results or take the appropriate actions • staff did not include the relevant clinical information in his referral for an urgent bone density scan in April 2024, so it was rejected by the radiology team • a consultant spinal surgeon ignored his letter of 8 April where he asked for more help in progressing his treatment and managing his back pain • he experienced significant delays waiting for a pre-operative appointment • the pain management team delayed sending a letter to his GP from 4 September to 18 October to give instructions about his pain medication.

6. Mr N says as a result, he experienced unnecessary delays in his treatment, which prolonged his severe pain and made his mobility worse as he has developed permanent nerve damage. Mr N explains he was bed-bound for 12 months and had to use strong opiate medication to manage his pain. Mr N explains the poor communication and administration errors increased his anxiety and frustration.

7. By bringing this complaint to us, Mr N would like:

• a full investigation into his concerns • financial remedy • apology and acknowledgment of failings from the Trust • service improvements.

8. Mr N has scoliosis (curvature of his spine) which he thinks is due to wear and tear caused by playing sports when he was younger. Mr N has also previously experienced slipped discs. He had spinal surgeries in 1996, 2005 and 2009.

9. Mr N’s back pain worsened gradually following his surgery in 2009, and he had many different pain treatments and medications to manage his symptoms.

10. Mr N was registered on the Trust’s neurosurgery waiting list on 30 December 2022. He attended his first appointment on 27 January 2024 and had an X-ray and MRI scan on 5 February.

11. On 8 March, Mr N went to A&E. He said he was in so much pain he could hardly move, and he knew something was wrong. He was already taking strong painkillers including morphine, gabapentin and oxycodone to manage his pain at this time. Mr N had an MRI scan and X-rays at A&E and was then discharged home as he had an upcoming follow-up appointment with the neurosurgery team.

12. Mr N attended the planned consultant appointment on 26 March. The consultant spinal surgeon made a plan to consider him for further spinal surgery, following additional scans and review. He also referred Mr N to another consultant spinal surgeon for a second opinion.

13. Mr N continued to experience pain and contacted the Trust on several occasions to progress his care.

14. Mr N was reviewed by the second consultant in June and was discussed by the complex spinal multi-disciplinary team (MDT). Mr N had a further appointment in July, and the consultant confirmed the plan for spinal surgery. The consultant listed Mr N for surgery and referred him to the pain clinic, noting Mr N’s pain management would be very challenging following the surgery.

15. Mr N and his partner continued to contact the Trust over that summer to progress his care. Mr N said they encountered difficulties speaking to the relevant secretaries, left messages which were not responded to and were given conflicting information.

16. Mr N had a phone appointment with the pain clinic on 4 September. He had a pre-operative assessment on 30 September and had his surgery at the end of the year. Mr N said he felt immediately better following his surgery.

20. 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.

21. We also look at whether there are signs the events complained about had a negative effect which the organisation has not put right.

22. We have done this and have either found no indications something has gone wrong, or we have found the Trust has already done enough to put right the impact of events.

Removal from the neurosurgery waiting list

23. Mr N complains in November 2023, staff incorrectly removed him from its neurosurgery waiting list, despite him confirming by email in September he still wanted an appointment.

24. Mr N said he received a letter from the Trust on 13 September 2023 asking him to confirm if he still wanted to have an appointment with the neurosurgery department. Mr N said he followed the instructions on the letter and sent an email confirming he still wanted to be seen.

25. Mr N said he received a further letter from the Trust on 24 November 2023 which said it had removed him from the neurosurgery waiting list. In the letter, the Trust said it had sent Mr N a letter and attempted a phone call or text message to his primary contact number, but Mr N had not responded to its request for contact.

26. Mr N said he responded to the letter on the day he received it, by email. He said he did not receive a phone call or text message. He said when he contacted the hospital, the staff member he spoke to could not find a record of the letter he received on 13 September nor his email reply. He said they also could not find a record of an attempt to call him or send him a text message and Mr N said they apologised.

27. Mr N said the staff member told him they were adding him back to the waiting list, in the same position he would have been in had he not been removed and he would have an appointment by September 2024.

28. In its complaint response, the Trust said it was unable confirm why it had not received Mr N’s email on 13 September 2023 and apologised for the inconvenience he had been caused. The Trust sincerely apologised Mr N had not received either a phone call or text message, and a further letter before it sent him the final discharge letter.

29. The Trust told Mr N if any patient replied to a discharge letter to say they had either previously replied or not received the previous correspondence, the Trust would automatically reinstate them to the waiting list at the same date and time so as not to be disadvantaged at all. The Trust told Mr N it was reassured the failsafe worked in his case.

30. We asked the Trust where Mr N was on the waiting list when he was removed from neurosurgery waiting list in November 2023 and when he would have been seen had the removal not occurred.

31. In an email to us, the Trust said Mr N was registered on 30 December 2022, removed from the list in November 2023 and was seen on 26 March 2024. The Trust said Mr N was approximately 48 weeks on the waiting list at the time of removal and said at that time, the wait for an appointment was approximately 78 weeks. The Trust said Mr N was seen at 64 weeks.

32. Our complaint standards say wherever possible, staff should explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies that openly reflect the impact on the people concerned. We can see the Trust did this.

33. As the Trust added Mr N back to its waiting list at the same position, we cannot see the Trust delayed providing Mr N’s care. However, we appreciate the Trust’s administrative errors would have resulted in Mr N being inconvenienced.

34. One of the outcomes Mr N seeks to resolve his complaint is financial remedy. When deciding on a level of financial compensation, we use our severity of injustice scale (our scale) to guide what we ask an organisation to provide. We would place Mr N’s injustice at level one on our scale.

35. Our scale says injustices at level one will usually be those such as annoyance, frustration, worry or inconvenience, typically arising from a single incidence of maladministration or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wider impact.

36. For these reasons, we would place Mr N’s injustice at level one on our scale. We consider an apology is an appropriate remedy for an injustice of this nature.

37. We appreciate Mr N’s concern and frustration at the Trust removing him from its waiting list incorrectly. We can see the Trust has apologised for this and do not consider the Trust needs to take any further action in respect of this part of Mr N’s complaint.

Staff did not treat Mr N with appropriate urgency following scan results

38. Mr N attended A&E on 8 March 2024 with severe back pain. He had scans during this attendance. Mr N said these images showed new degenerative changes compared to the scans he had on 5 February and showed signs of cauda equina. Cauda equina syndrome is a serious condition affecting the nerves at the lower end of the spinal cord which requires urgent treatment. Mr N complained his A&E attendance did not generate the required urgency for his spinal treatment and said the consultant spinal surgeon did not review his A&E images during his follow-up appointment on 26 March.

39. In its complaint response the Trust said it discharged Mr N from A&E as he had an upcoming outpatient appointment with the spinal team on 26 March. It said if a patient is discharged with a follow up review already planned, the images are not passed back to the relevant outpatient department as the A&E department deem the patient fit for discharge. It later said the spinal consultant did have the images from Mr N’s A&E attendance available to review at Mr N’s outpatient appointment on 26 March.

40. We asked the Trust to clarify whether the spinal consultant had the A&E images available to review during Mr N’s follow up appointment on 26 March. The Trust told us the images were not sent to the consultant spinal surgeon directly following Mr N’s A&E attendance but were added to Mr N’s records where they were available for viewing as and when needed.

41. NICE guidelines outline red flags of back pain. Red flags are warning signs that may indicate a serious underlying condition requiring urgent medical evaluation. It is documented in Mr N’s medical records, during Mr N’s A&E attendance, A&E staff considered red flags for cauda equina syndrome. Due to Mr N’s symptoms, A&E staff formed a suspected diagnosis of cauda equina syndrome and arranged for Mr N to have an urgent MRI scan and for the spinal team to review Mr N.

42. The spinal team reviewed Mr N in A&E and documented Mr N’s MRI scan from that attendance was possibly slightly worse than the images from February. They documented their examination of Mr N again considering the red flags in back pain.

43. Our clinical adviser said Mr N’s images from 8 March show a very slight deterioration from 5 February, but there was no indication for urgent surgery. They said the images from 8 March show a worsening disc prolapse (also known as a slipped disc, when soft tissue between the spinal bones bulges outwards) but there is no compression of the cauda equina.

44. Our clinical adviser explained the only reason to perform urgent surgery is if a patient has cauda equina syndrome and Mr N did not have this. They said the spinal team did not document any radiological or clinical evidence Mr N had cauda equina syndrome during his A&E attendance.

45. During Mr N’s A&E admission, the spinal team documented they discussed management options for N’s symptoms. They said these would be: • conservative with pain killers, pain team review and physiotherapy • local (spinal) injection for pain relief • last option would be major surgery.

46. These options are in line with BASS patient information for stenosis. Spinal stenosis is a narrowing of the spinal canal which can cause back and leg pain. Staff reporting on Mr N’s MRI scans in February and March noted spinal canal stenosis in the images amongst their findings.

47. It is documented in the clinic letter from Mr N’s follow up appointment with the spinal team on 26 March, the consultant discussed the option of surgery with Mr N. They wrote Mr N had already tried physiotherapy and felt no pain management was helping him.

48. The consultant spinal surgeon noted surgery may be very extensive and it was a big question whether the outcome would be satisfactory or not. They reviewed Mr N’s x-rays and noted his bones may be soft. They said they would arrange further bone density scans for Mr N. They said they would also refer Mr N for a second opinion with a colleague to see whether there would be benefit from Mr N undergoing this surgery.

49. Our clinical adviser said adult scoliosis repair is massive surgery. They explained the more you operate on the spine, the more you destabilise the spine. Our clinical adviser said given the high-risk nature of Mr N’s surgery, this required careful assessment and a prolonged consent to consider the risks and benefits. They said high-risk spinal surgery should not be done urgently unless a patient has cauda equina syndrome.

50. While we cannot determine whether Mr N’s consultant reviewed his images from both February and March, we are assured by the Trust the images were available. Considering the evidence available, we have not found any indications of failings in the way staff prioritised Mr N’s care.

51. We saw A&E staff acted in line with guidance when they considered Mr N’s red flag symptoms, suspected Mr N might have cauda equina syndrome and accordingly arranged further imaging and requested a spinal review. We saw spinal team staff determined Mr N did not have cauda equina syndrome and acted in line with guidance by carefully considering surgery in view of the risks involved, rather than proceeding urgently.

52. We understand how distressing it must have been for Mr N to be in severe pain for such a long time and appreciate this must have been a very difficult time. We in no way mean to diminish Mr N’s distress. We hope he can understand why the Trust were cautious and took extra steps before agreeing to operate.

Bone density scan referral

53. Mr N complains staff did not include the relevant clinical information in his referral for an urgent bone density scan in April 2024, so the radiology team rejected it.

54. In his complaint to the Trust, Mr N said during his appointment on 26 March, the consultant spinal surgeon told him a bone density scan was required before his next appointment with the surgical team. This is because if the scan results were not favourable, his surgery would not be able to go ahead. Mr N said he was therefore under the impression the bone density scan was required urgently. We have not found indications the scan was required urgently but we can understand why Mr N thought it was.

55. Mr N said he received a letter on 4 April informing him his next appointment with the spinal surgery team was arranged for 3 July. This prompted him to try to chase up his bone density scan, and he said he contacted the Trust several times to do this. He said staff told him the scan referral was ‘back’ with the consultant spinal surgeon.

56. In its complaint response, the Trust said the radiology department rejected the first bone density scan request. This is because Mr N was below the minimum age to automatically accept the referral on the grounds of assessing for surgery only. The Trust apologised for any stress and inconvenience this had caused Mr N.

57. We appreciate Mr N’s frustration his first bone density scan referral was rejected. Mr N has told us of the attempts he made to chase this up throughout April and we recognise he wanted to ensure potential delays to this scan did not delay his surgery.

58. Mr N told us the consultant’s secretary called him on 8 May and then advised him he needed to have his second opinion appointment with the second consultant spinal surgeon before having the bone density scan. In its complaint response the Trust explained this was because the second consultant firstly needed to agree that surgery was the best option, or the scan would not be required.

59. It is shown in Mr N’s clinical records he had a bone density scan on 1 July. The consultant spinal surgeon listed him for surgery that day. At this time the consultant required Mr N to also be reviewed by the pain clinic before his surgery. Mr N had a pain clinic consultation on 30 September. The consultant also contacted another consultant spinal surgeon requesting support for Mr N’s surgery on 20 September.

60. Given the further actions required by the consultant before Mr N’s surgery took place, we cannot say his first bone density scan referral being rejected caused any delay to the date of his surgery. We do however recognise the inconvenience to Mr N and appreciate he felt the need to chase up.

61. Our complaint standards say when things go wrong, staff should give people meaningful and sincere apologies, and we can see the Trust did this in its complaint response.

62. We would place Mr N’s inconvenience at level one on our severity of injustice scale, and we feel an apology is an appropriate remedy. We do not think the Trust need to take further action to remedy this part of Mr N’s complaint.

Letter ignored by Trust staff

63. Following Mr N’s appointment on 26 March, the consultant spinal surgeon referred Mr N to a colleague for a second opinion. Mr N said he received a letter from the Trust on 4 April advising him of his next appointment with the spinal surgery team on 3 July.

64. On 8 April, Mr N wrote to the consultant he had seen in March to ask for help in progressing his treatment and managing his back pain. He said staff ignored his letter.

65. In its first complaint response, the Trust said it had no record of receiving this letter. Mr N challenged this point. In its second complaint response, the Trust apologised for saying it had not received Mr N’s letter and confirmed it had. It said it did not reply to Mr N as he had recently been seen in clinic, and the consultant had already referred Mr N to their colleague for further input and advice.

66. In Mr N’s complaint to the Trust, he said he phoned the consultant spinal surgeon’s secretary on 16 April who said she had received the letter and taken it to the consultant’s office. Mr N said he phoned the consultant’s secretary again on 19 April who advised the consultant had been off sick that week.

67. Mr N said he spoke to his GP on 23 April who advised he would email the consultant to try to expedite his next appointment. Mr N said the consultant’s secretary called him on 24 April to say his next appointment had been brought forwards from 3 July to 5 June. Mr N said his appointment was expedited following the contact with his GP.

68. Our principles of good administration say public bodies should be customer focused, behave helpfully and deal with people promptly. We are satisfied the Trust did this. Mr N told us he was in contact with the consultant’s secretary by phone the week after sending the letter. He also said the secretary phoned him to inform him his next appointment was later brought forward by four weeks. We are not making a decision on whether his appointment was brought forward as a result of his letter, or intervention from his GP, but we are satisfied the Trust met his request to expedite his treatment and communicated this to him.

69. We have not found any indication the Trust ignored Mr N’s letter. We would not necessarily expect a consultant to respond to a patient’s letter in writing and do not think this would be proportionate, especially considering Mr N’s phone contact with the consultant’s secretary after he had sent his letter. We appreciate Mr N’s frustration at the waits for his treatment. We hope we have explained why we do not think the Trust got things wrong in this case.

Pre-operative appointment delayed

70. Mr N complains he experienced significant delays waiting for a pre-operative appointment.

71. It is documented in Mr N’s medical records, the consultant spinal surgeon listed Mr N for surgery on 1 July. The consultant also referred Mr N to the pain clinic on the same day, for a review prior to his surgery. Mr N was reviewed by the pain clinic on 4 September. It is documented in Mr N’s medical records, the consultant contacted another surgeon on 20 September to request assistance with Mr N’s surgery.

72. GMC Good Medical Practice guidance says doctors should consult colleagues or refer a patient to another suitably qualified practitioner when this services the patient’s needs. We can see the consultant spinal surgeon acted in line with this guidance when they sought assistance from a colleague for Mr N’s surgery.

73. Mr N had his pre-operative appointment on 30 September. The Trust wrote to Mr N on 28 November informing him of a surgery date of 12 December.

74. We asked the Trust about its process for booking a pre-operative appointment for a patient. In an email to us, the Trust said at the time, it did not automatically book pre-operative appointments when a patient was listed for surgery. It said it only carried out pre-operative appointments when there was a provisional date for surgery. This was to prevent the need for multiple repeat pre-operative appointments.

75. Our clinical adviser said the Trust’s policy to arrange a pre-operative appointment when there was a provisional date for surgery was reasonable. They said there is no national guidance on how long a pre-operative assessment is valid for and local organisations will have their own policies. They explained there is no point in doing a pre-operative assessment too early as you risk needing to repeat it if surgery does not go ahead within the validity period.

76. NHS England guidance says validation and expiry times vary across pre-operative assessment services nationally and notes a survey across England found reported times for expiry varied between 12 weeks and six months.

77. The Trust told us its pre-operative appointments are valid for three months.

78. The Trust’s pre-operative assessment validity period aligns with the validity periods of other Trusts in England. Given the consultant spinal surgeon wanted Mr N to be reviewed by the pain clinic in advance of his surgery and needed to co-ordinate Mr N’s surgery with a second consultant, it was not unreasonable his pre-operative assessment was not arranged earlier.

79. We appreciate Mr N had a long wait for his surgery and was in pain during this time. We understand how hard this must have been. Mr N has told us he and his partner made several attempts to chase up his pre-operative appointment, and the medical secretaries did not always respond to him. We appreciate this must have been very frustrating, particularly while he was in pain. We have not found indications the Trust’s actions delayed Mr N’s pre-operative assessment. In making this decision, we in no way mean to diminish Mr N’s distress.

Pain clinic letter delayed

80. Mr N complains he had a phone consultation with a pain clinic doctor on 4 September and the clinic letter with instructions for his pain medication was not sent to his GP until 14 October. Mr N received a copy of this letter on 18 October.

81. In its complaint response, the Trust apologised to Mr N for the delay between his clinic appointment and the receipt of the letter. It said letters are prioritised and typed in chronological and clinical priority order.

82. We asked the Trust what the normal length of time was for pain clinic letters to be typed up and sent to a patient’s GP in September 2024. The Trust told us the waiting time was around four weeks due to staff sickness. It said the waiting time is now one week.

83. The Trust told us Mr N was known to the pain clinic service at this time, and his clinic letter would have been expedited if clinically indicated or urgent. It is documented in Mr N’s clinical records the consultant spinal surgeon had listed Mr N for elective (non-urgent surgery). Our clinical adviser agreed Mr N’s surgery required careful planning due to its complexity and was not urgent.

84. GMC Good Medical Practice says doctors must prioritise patients based on their clinical need. We have not seen indications Mr N’s pain clinic letter should have been prioritised as urgent. We appreciate Mr N’s stress and frustration it took so long for the Trust to write his GP following his pain clinic appointment and hope we have reassured Mr N we cannot see the Trust got things wrong.

85. We understand how difficult it must have been for Mr N to have to wait for surgery when he was in such pain. Our decision does not wish to take away from the experience Mr N had. To summarise, we have not seen the Trust did anything in wrong in terms of the urgency of Mr N’s care, nor the administrative actions in responding to his letter, booking his pre-operative assessment, or sending out a clinic letter after he saw the pain team.

86. We recognise the Trust incorrectly removed Mr N from the neurosurgery waiting list and did not complete his referral for a bone density scan properly. We consider the Trust has already done enough to put right the impact we think these administrative failings had. Therefore, we have decided to take no further action.

1. We have carefully considered Mr N’s complaint about Northern Care Alliance NHS Foundation Trust (the Trust). We are very sorry to hear about the concerns he has about the care he received and that he was in severe pain while waiting for surgery. We appreciate this must have been a very difficult time.

2. Regarding staff not treating Mr N with appropriate urgency following his scans and A&E attendance, the Trust ignoring his letter, his pre-operative appointment and his pain clinic letter, we have not found indications staff got things seriously wrong.

3. Regarding the Trust removing Mr N from its neurosurgery waiting list and his bone density scan referral, we have decided the Trust has already done enough to put right the impact of these events on Mr N.

4. We understand Mr N was in severe pain while waiting for surgery and recognise this was a very difficult time for him. We appreciate he had a long wait. We are sorry this is not the outcome Mr N is hoping for.