An independent provider in the Wirral area

6. Mrs N complains about aspects of care and treatment she received from the Hospital before and after a total cemented hip replacement in June 2023.

7. Specifically, she said the Hospital: • failed to address her concerns about increasing pain, after her surgery on 27 June, 14 July, 25 July, 6 October, and 8 December 2023 • did not appropriately communicate the details of her procedure, during pre and post surgery discussions on 13 June 2023 • incorrectly referred her to an NHS Trust, for a second opinion and ongoing postoperative care on 8 December 2023.

8. Mrs N told us she feels her recovery was severely affected because the Hospital did not address her concerns and increasing pain in a timely manner. Physically she is less mobile and has lost fitness and independence, struggles to sleep and is in constant pain. Mentally, she feels she is lost confidence, been anxious, depressed, and withdrawn, has felt suicidal and feels unable to participate in daily activities. Her time and finances have also been impacted.

9. She believes because she was incorrectly referred to an NHS Trust, this also delayed her post-operative Magnetic Resonance Imaging (MRI) scan. An MRI scan creates detailed images of inside the body using a strong magnetic field and radio waves.

10. Mrs N explained she had to chase her post-operative treatment, as she felt it was not provided in a timely manner. She also told us she had to pay for private physiotherapy, after the NHS physiotherapy ended. She also said she has had to pay for private mental health treatment, because of the actions of the Hospital.

11. Mrs N is looking for financial remedy for non-financial loss and a reimbursement of costs for the private treatment she has already funded.

12. This brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

13. In mid June 2023, the Hospital carried out a cemented hip replacement operation on Mrs N. A cemented total hip replacement is an operation where a damaged hip joint is replaced with metal, ceramic, or plastic parts. The surgeon fixes the parts straight away with fast setting medical grade bone cement.

14. Mrs N attended five face to face appointments with the Hospital consultant between the end of June and early December. These appointments were to discuss pain following her surgery. The Hospital also requested a further X-ray in mid July to reassure Mrs N.

15. Mrs N also had several appointments with her GP between the end of June and the beginning of October. There were to discuss her ongoing pain and review her pain medication.

16. Mrs N attended group physiotherapy at the Hospital, in late June and July.

17. In August and September, Mrs N attended one to one physiotherapy appointments at the Hospital. At the September appointment, the Hospital told Mrs N there was no further pain management it could offer. It agreed to follow up with her in six weeks.

18. In late September, a GP requested a further X-ray at Mrs N’s request. In early November, Mrs N attended her GP surgery for a full blood count (this is a blood test which allows doctors to check and investigate causes of symptoms including infection or pain).

19. In early December, the Hospital consultant referred Mrs N to an NHS Trust consultant for a second opinion.

20. Between mid December and mid January 2024, Mrs N attended various GP appointments and individual physiotherapy appointments at the Trust.

21. In mid January Mrs N met the Trust consultant. The Trust referred her for an MRI.

22. At the end of January, the Hospital telephoned Mrs N to say it could do the MRI. The following week, the Hospital told her the Trust consultant did not want the MRI completed at the Hospital.

23. At the beginning of March, Mrs N attended an MRI scan at the Trust.

24. Mrs N had a second appointment with the Trust consultant in mid March. A bursitis shown on the MRI scan results was given as a possible source of pain. A bursitis is when the fluid filled sacs (the bursa) cushioning the joints have become painful and swollen.

25. The Trust referred her for a computerised tomography (CT) scan of her left hip. A CT scan takes detailed pictures of the inside of the body.

26. It also referred Mrs N for a trochanteric bursitis injection (TBI). A TBI is a procedure involving an injection of medication directly into the trochanteric bursa. The trochanteric bursa is a fluid filled sac in the hip area.

27. Mrs N attended the CT scan in early April. She attended the TBI in mid April. She had a further scan appointment was in early May. The Trust radiologist was unable to find the bursa on the scan, and the injection did not go ahead.

28. In early July Mrs N had a pelvis MRI scan at the Trust. In late July she attended an appointment with the Trust consultant. The Trust consultant sent a follow up clinic letter to Mrs N’s GP. It said Mrs N’s recovery was slow and surgery was not a solution to her pain.

The Hospital failed to address her concerns about increasing pain, after her surgery, in June, July, October and December 2023

32. 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 have not found any indications that something has gone wrong.

33. Following Mrs N’s operation in mid June 2023, she believed the surgery had not been successful. She felt her pain should have stopped after the procedure and it did not. By December, she said the pain in her groin (the area where the legs meet the front of the body) was worse than before surgery.

34. Mrs N told us she felt she experienced a lack of postoperative care around her increasing pain. She told us she raised concerns with the Hospital on five separate occasions between June and December. She told us she was not listened to and poorly communicated with.

35. She said a private physiotherapist believed a tendon repair done during surgery could be a significant cause of her pain.

36. The Hospital said it reviewed Mrs N on the normal postoperative pathway and in additional consultations. It ruled out the most common causes of pain, post operative infection, and any issues with the implant. It said the concerns Mrs N reported are common and the range of recovery varied for each patient.

37. The Hospital looked at an earlier spinal X-ray which had been taken before Mrs N’s surgery. It noted lower lumbar and lumbar sacral degenerative changes. The lower lumbar area is the bottom two or three vertebra of the back. Vertebrae are the individual bones that make up the spine. The lower lumbar vertebrae support the upper body and enable movement. The lumbar sacral area is where the bottom of the spine connects to the pelvis which supports the lower back and legs. Degenerative changes to this area show wear and tear in the lower spine. This often leads to pain, stiffness, and reduced movement. It said this scan suggested Ms N’ pain was continued scar healing pain and possible pain from her back.

38. The Hospital held a multi-disciplinary team (MDT) meeting in November to discuss Mrs N. An MDT is a group of healthcare professionals who work together to provide care and treatment for patients. It said degenerative tendons are not an unusual finding during total hip replacement surgery in patients of Mrs N’s age group. The Hospital MDT said the tendon repair during surgery was not likely to be the basis of the ongoing pain. It said Mrs N’s outcome was suboptimal. This means a patient did not achieve the outcome expected from the surgery.

39. Mrs N’s medical records show a physiotherapy note in July saying the hip pain was unlikely to be caused by the abductor repair. This is an operation to fix a tear in the tendons on the outside of the hip which help stabilise the joint.

40. The Hospital requested a second opinion from Trust colleagues in the NHS. This led to a new MRI scan. Both the Hospital and Trust consultants felt the surgery had gone well. The Hospital said no further tests should be completed at the Hospital until the Trust had given its second opinion.

41. GMC Good medical practice says, in providing good clinical care, doctors should adequately assess a patient’s condition. Doctors should promptly provide or arrange investigations when suitable. It also says doctors should propose effective treatments and consult colleagues as required.

42. Mrs N’s medical records show the Hospital examined her on multiple occasions in November and December 2023. They further show it referred her for physiotherapy, X-rays and blood tests, and prescribed pain medication. There are no records to show her pain was caused by the tendon repair during her hip replacement surgery.

43. Mrs N’s medical records show the Hospital completed tests to try and find any obvious issues that were contributing to Mrs N’s pain. They also indicate the Hospital considered blood tests and X-rays her GP requested, during this period.

44. When the cause of her pain could not be identified, the Hospital sought a second opinion, consulting colleagues. This was in line with GMC guidance.

45. Our adviser reviewed Mrs N’s medical records. They told us Mrs N was assessed on multiple occasions, by her doctors and physiotherapists. They further said the X-rays and investigations were appropriate.

46. Mrs N told us how debilitating and upsetting the pain was for her. We do not underestimate the impact this had on her.

47. Based on the evidence we have not seen any indication the Hospital did anything wrong when Mrs N raised concerns of pain. We are satisfied the care and treatment provided by the Hospital, in relation to Mrs N’s pain concerns, was in line with GMC Good medical practice.

48. We recognise she has had a difficult recovery from her total hip surgery. We hope we have reassured Mrs N the Hospital followed the correct pathway and provided her with appropriate care, in line with guidance.

The Hospital did not appropriately communicate the details of Mrs N’s procedure, during pre and post surgery discussions on 13 June 2023

49. Mrs N said the communication before and after surgery did not correctly explain the details of the hip replacement procedure. She believed the Hospital should have given her the opportunity to choose which hip joint she received.

50. She said she needed to understand what the limitations of the hip, chosen for her, would be after her surgery. She said the Hospital consultant did not explain any limitations to her before the surgery. Mrs N also wanted to understand why the Hospital consultant felt a tendon repair was necessary during the surgery and how they carried out the repair.

51. The Hospital said the consultant makes the decision on the type of hip to use. Their decision is based on many factors including the consultant’s practice and the age of the patient.

52. The Hospital further said, for patients over the age of sixty, its consultant only fits cemented hip replacements. Mrs N is in this age bracket. The Hospital MDT said the surgeon used a suitable joint, and it was happy with the approach. It also said tendon damage is often seen when hip replacement surgery takes place.

53. The Hospital said its consultant routinely meets with a patient after surgery to discuss what happened during the operation. Mrs N’s medical records do not show any evidence of this conversation, after her surgery. The Hospital said it is not expected practice for consultants to add this conversation detail to a patient’s medical record.

54. Mrs N’s medical records show she attended an appointment with the Hospital consultant in March 2023. A follow up letter was sent to Mrs N’s GP practice. Mrs N also received a copy of the letter. It said Mrs N had been diagnosed with left hip osteoarthritis (osteoarthritis is a common condition where the surface of the joint becomes rougher and does not move as smoothly).

55. The letter said Mrs N and her husband discussed treatment options at length with the consultant. Mrs N chose to go down the surgical route. The letter said the management plan was for a left cemented total hip replacement. It said the consultant told Mrs N the risks of surgery and she signed the consent form at the consultation.

56. Mrs N’s medical records show a further letter also dated March 2023. This is from the Hospital to Mrs N’s GP practice. During our investigation we confirmed the date on the letter should have been 26 July. The letter followed up a July post surgery consultation between Mrs N, her husband, and the Hospital consultant.

57. The letter said Mrs N asked if her hip replacement had a ceramic ball and why the consultant had fitted a cemented total hip replacement. The letter confirmed there was a detailed conversation in the appointment on 26 July about cemented and uncemented total hip replacements. During the conversation Mrs J discussed the reasons for and against each one with the consultant.

58. GMC Professional Standards says all patients have the right to be involved in decisions about their treatment and care, and decision making must include meaningful dialogue and the exchange of relevant information relevant to the patient. It says medical professionals must be satisfied they have a patient’s consent before providing treatment.

59. The Hospital sent a consultation follow up letter to Mrs N dated 31 March. This clearly confirmed the cemented hip replacement joint and said how the surgery would be completed.

60. Our adviser said the Hospital acted in line with GMC Professional Standards when discussing the treatment options and giving relevant information.

61. NICE guideline NG157, says surgeons should only use hip replacement implants if evidence shows they are unlikely to need replacing in more than 5% of patients within ten years. This would show the prothesis would meet a minimum standard for long term safety and effectiveness.

62. NICE TA304 says surgeons choose not only the type but also the brand of hip prosthesis a patient receives. This is driven by factors including the surgeon's training, their understanding of which prostheses perform best, clinical data and experience using different prostheses, among other factors.

63. Our adviser told us the cemented hip implant was appropriate. The Hospital acted in line with NICE TA304.

64. In July, after surgery, Mrs N, and her husband, discussed the procedure in detail again with the Hospital consultant.

65. Following Mrs N’s complaint, the Hospital told us the consultant has reviewed their practice and now records the details of any post surgical discussions and includes them in the medical notes.

66. Based on the evidence we have seen, we are satisfied the Hospital acted in line with GMC Professional Standards, NICE NG157 and NICE TA134. We have seen no indication of a failing in with how Hospital the communicated details of Mrs N’s procedure, during pre and post surgery discussions.

The Hospital incorrectly referred her to an NHS Trust, for a second opinion and ongoing postoperative care on 8 December 2023

67. In early December, a Hospital consultant arranged for Mrs N to have a second opinion. The Hospital referred Mrs N back to a Trust consultant, within the NHS, who also undertook private work at the Hospital.

68. Mrs N believes she should not have been transferred into the NHS. She further believes this delayed her MRI scan.

69. Mrs N had an appointment with the Trust consultant in mid January 2024. They referred Mrs N for an MRI scan.

70. Mrs N said the Hospital called her at the end of January. It said it wanted to speed up the MRI scan, and it could be done at the Hospital. Mrs N said she contacted the Hospital a week later. It then told her the Trust Consultant did not want her to have the MRI at the Hospital. She believes this was because they wanted to keep their NHS and private work separate.

71. The Hospital wrote to Mrs N in February. It said it understood she was still in pain and the Hospital consultant had said he was unable to identify a cause. The letter confirmed the Trust consultant had referred her for an MRI scan and a follow up Trust appointment would be arranged to discuss her results within the NHS. It said “it’s important you remain within the NHS for your MRI scan and follow up consultation to ensure your care is streamlined and prevent any further delays.”

72. It also said it should do no further tests until Mrs N had received her second opinion.

73. Mrs N attended the MRI scan at the Trust in early March.

74. Mrs N’s medical records show the Hospital completed several tests before the Trust MRI scan, to identify the reason of her pain. None of the tests showed a clear cause of Mrs N’s pain.

75. The Hospital said the Trust consultant was a revision service consultant, in a letter to Mrs N dated mid August. A revision service is a specialist service to assess and treat patients whose hip replacement has not worked as intended, and may need to be corrected, repaired, or replaced.

76. This is more complex and a higher risk surgery than the first hip replacement surgery. The Hospital does not do revision surgery.

77. GMC GMP guidance says consultants should work collaboratively with colleagues, recognise and work within the limits of their ability and to seek advice where a case is complex, outcomes are uncertain, or the limits of their competence are reached.

78. Our adviser said either the Hospital or Trust could have given Mrs N a second opinion.

79. They further said it would be reasonable for the Hospital to refer Mrs N to the NHS Trust if there was a concern she may have needed revision surgery. This is because the Hospital does not do revision surgery. It was also correct for the MRI scan to take place at the Trust. This was because the Hospital was waiting for the Trust to complete its second opinion before arranging any more tests.

80. We asked our adviser if the transfer of care delayed Mrs N’s MRI scan. There was a two month wait between the first Trust consultation at the beginning of January and the MRI scan at the beginning of March. Our adviser said this would be the average waiting period at most NHS trusts for a routine MRI scan.

81. The Trust MRI was taken almost six months following Mrs N’s surgery and showed no significant concerns. It did show a bursitis. The Trust referred Mrs N for injection treatment for this in mid April. Our adviser said, it is unlikely that an earlier scan would have had any difference to her treatment and outcome.

82. From the evidence we have seen, we can see the Hospital could not find the cause of Mrs N’s pain. We are satisfied it followed GMC GMP guidelines and asked for a second opinion. The hip replacement was not working as intended and revision surgery may have been necessary to address the problem. We believe the referral to the Trust was reasonable as, if a problem were found, the Hospital would have been unable to do the necessary surgery if needed. This was also in line with GMC GMP guidance.

83. We believe the Hospital acted in line with GMC guidelines when it referred Mrs N to an NHS Trust for a second opinion.

84. We recognise Mrs N was in a great deal of unexplained and unexpected pain. This caused her a lot of frustration. We do not underestimate the impact this has had on her.

85. We understand how difficult it can be to make a complaint. We would like to thank Ms N for bringing her concerns to us.

1. We have carefully considered Mrs N’s complaints about the Hospital. We recognise Mrs N’s distress at the ongoing pain and the impact on her physical and mental health. We understand she told us this caused her significant distress.

2. We have looked at whether the Hospital failed to look at her concerns about increasing pain after her surgery. We believe it acted in line with guidance and have seen no indication that anything went seriously wrong.

3. We recognise Mrs N’s wish to understand the type of surgery she had. We also recognise the importance to her of understanding what happened during the surgery. We are satisfied the Hospital followed correct procedures in communicating Mrs N’s surgical procedure to her both before, and after the surgery, was carried out.

4. Mrs N was concerned she was incorrectly referred to an NHS Trust for a second opinion, and it led to a delayed spinal magnetic resonance imaging (MRI) scan. An MRI scan creates detailed images of inside the body using a strong magnetic field and radio waves. We have found no indication the second opinion should not have been made. We believe the MRI scan or any further treatment after the scan was not delayed unnecessarily.

5. We recognise how important this complaint is to Mrs N and would like to take this opportunity to thank her for bringing it to our attention. We hope our explanations below show how we have considered this complaint.