An independent provider in the Sheffield area

7. Miss X complains the Hospital and the Trust failed to provide the appropriate care and treatment after she had a microdiscectomy. She complains:

The Hospital

• between October 2021 and February 2022, the consultant did not listen despite numerous calls that she was in pain, and she was not given appropriate care until four and a half months after surgery.

The Trust

• she was not informed the pain would be life-long or given an update of the findings after an open-biopsy in February 2022 • in August 2022, a CT guided biopsy was carried out whilst she was awake and after she was not informed the pain would be life-long or given an update of the findings after an open-biopsy • she was not given a diagnosis of arachnoiditis (inflammation of the membrane that surrounds and protects the spinal cord) until two weeks after the legal threshold in January 2024.

8. She states the impact was:

The Hospital

• this caused a very serious infection which led to her needing further surgeries, antibiotics, and prolonged treatment.

• it caused long-term pain and a lack of reflexes and balance in her right foot and leg.

• a pain management plan was delayed, and she had to wait two years to start physiotherapy.

• she is no longer able to work.

The Trust

• it caused long-term pain and a lack of reflexes and balance in her right foot and leg.

• a pain management plan was delayed, and she had to wait two years to start physiotherapy.

• she is no longer able to work.

• the decision was made to stop the CT guided biopsy, and a sample was not collected.

• it affected her mental health and caused further stress

9. She would like an outcome of service improvements and a financial remedy from both the Hospital and the Trust.

10. Miss X had an L5/S1 microdiscectomy in her back (surgery for a disc in the lumbar spine that has slipped out of place causing it to press on nearby nerves which can cause pain, weakness and numbness) on 6 October 2021.

11. Miss X received her surgery with the Hospital and was under its care until February 2022 when this care was transferred to the Trust.

17. Before we decide if we should conduct a detailed investigation of a complaint, we should 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 consider any gaps between the two and whether this amounted to a maladministration or service failure.

18. Having done so, we have not found a maladministration or service failure.

The Hospital

Post surgery care

19. Miss X complains between October 2021, and February 2022 the Hospital did not give her the correct post-surgery care.

20. She says in the months following her surgery she experienced severe pain and contacted her consultant multiple times about this as she believed there was something wrong. She says her calls were either not returned or when she was seen or spoken to she was told she was fine.

21. Miss X says it was not until her three-month check-up, which she says was closer to four months, that an MRI scan (magnetic resonance imaging - a type of X-ray) was organised as she was still in pain. We understand how distressing and frustrating it must have been for her to endure such discomfort while feeling her concerns were not being adequately addressed by the Hospital.

22. Due to the amount of time that has passed since these dates we are not able to gain a call log from Miss X or the Hospital.

23. Miss X had a consultation one month following her spinal surgery. During this consultation it was understood Miss X’s wound had healed nicely and her right ankle weakness had recovered. At this appointment Miss X was still in pain in her right buttock.

24. Miss X had a further post-surgery consultation at the end of January 2022. This was almost four months after her surgery. At this consultation records show Miss X’s foot drop had resolved but she was complaining of pain in her right leg that had gotten worse in the last two-three weeks. The consultant requested an MRI scan with contrast.

25. We have not relied on any guidance or standards to reach our decision for this complaint as there is no set guidance on post-surgery appointment time frames and consultations. Therefore, we have relied on the expertise and clinical experience of our adviser to provide us with information, understanding and expectations surrounding Miss X’s complaint.

26. After a conversation with our adviser, we understand at Miss X’s one month appointment it would have been very normal for some pain to be present after a surgery of this nature. We also understand some improvement to Miss X’s condition would have been considered positive and therefore it would have been entirely reasonable that no worries were raised at this stage and that no MRI was performed.

27. We also understand at Miss X’s next post-surgery consultation worsening pain would have meant it was reasonable that concerns may have been raised and that further testing carried out. We can see at this stage an MRI was organised.

28. Regarding the delay of almost a month to Miss X’s three-month post-surgery consultation our adviser explained due to a COVID-19 backlog this delay would have been entirely reasonable. They also explained Miss X’s pain had only been worsening for two-three weeks and therefore had the appointment taken place at three months Miss X’s symptoms would not have prompted a scan to take place or raised any concerns.

29. Based on this evidence we consider the Hospital has given the correct care and treatment to Miss X post-surgery. At Miss X’s one month consultation she did not have symptoms that would have prompted any further action to be necessary. We see the delay of almost a month to Miss X’s next post-surgery check-up was entirely reasonable and unavoidable due to a backlog from COVID-19. At Miss X’s next post-surgery consultation when she presented with worsening pain an MRI was performed and she was treated with surgery and antibiotics in a reasonable time frame.

30. We do not see a gap between what should have happened and what did happen in relation to this complaint and therefore do not see a maladministration or service error.

31. For these reasons we will not consider this issue further.

Sheffield Teaching Hospitals NHS Foundation Trust.

CT guided biopsy

32. Miss X complains in August 2022 a CT guided biopsy (a procedure using computerised tomography (CT) imaging to precisely guide a needle to collect a tissue sample) was incorrectly carried out whilst she was awake. She explains due to the amount of pain this error caused her, the biopsy was unable to be completed. We are sorry to hear of the pain Miss X experienced and understand this must have been a distressing time for her.

33. Prior to the CT guided biopsy, Miss X signed a consent form for this procedure. This said the procedure will involve local anaesthesia.

34. Miss X was given 20mg of temazepam sedation one hour before the procedure and 10ml of lidocaine as local anaesthesia during the procedure.

35. During the biopsy the needle was unable to be advanced beyond the cortex (outer layer) of the bone and an alternative technique to penetrate the cortex more effectively was offered however, Miss X declined this due to being in pain.

36. We have not relied on any guidance or standards to reach our decision for this complaint as there is no set guidance on sedation during spinal biopsies.

37. After a conversation with our adviser who used their previous experience and expertise to give advice on the subject, we understand spinal biopsies are routinely done under sedation and local anaesthetic and it would be unusual for this procedure to have been carried out under general anaesthetic. We also understand the dose of sedation and local anaesthesia used would have been a reasonable amount for a procedure of this nature.

38. Based on the evidence we see the Trust has given the correct care and treatment to Miss X during her CT guided biopsy.

39. We consider Miss X consented to this procedure under local anaesthetic and both local anaesthetic and sedation were given to Miss X. We also consider when Miss X stated she was in too much pain the procedure was stopped and the Trust considered other alternatives to gather information in the form and blood tests and further MRI scans.

40. We do not see a gap between what should have happened and what did happen in relation to this complaint and therefore do not see a maladministration or service error.

41. For these reasons we will not consider this issue further.

Ineffective communication and diagnosis

42. Miss X complains there was ineffective communication from the Trust after an open biopsy took place in February 2022 as she was not updated on the findings or informed her pain would be lifelong. She also complains there was ineffective communication as she was not given a diagnosis of arachnoiditis (inflammation of the membrane that surrounds and protects the spinal cord) until two weeks after the legal threshold which stopped her considering taking legal action.

43. GMC Guidance on ‘sharing information’ lays out the expectations on medical professionals to give information to patients. It explains they should give information about: • their condition, likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition, including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.

44. Medical records show Miss X was seen post-operatively in the post-anaesthesia care unit (PACU) where she was told of the surgical findings.

45. Miss X was told she had an infected collection disk and there was an unfortunate complication of surgery. She was told this complication was a dural tear with cerebrospinal fluid (a leak of the clear fluid that cushions and protects the central nervous system). Miss X was also updated that there was a chance of the infection spreading and that this had already been discussed with microbiology and the appropriate treatment to prevent/treat this had started.

46. We see Miss X was told she had an infected collection disk, the options for treating this with microbiology services, and the likelihood of success when she was told there was potential that the infection may spread.

47. In relation to Miss X’s complaint that she was not diagnosed with arachnoiditis until after the legal threshold we cannot see anything to suggest the Trust intentionally kept the term ‘arachnoiditis’ from Miss X.

48. After a discussion with our adviser, we understand spinal infections can take years to heal and for the symptoms to improve. We understand it is hard to predict in the early stages, even with arachnoiditis on imaging, as to the extent, if any, of permanent neurological deficit or pain.

49. From the records we can throughout Miss X’s treatment she was regularly updated via reviews of her care. She was also given further blood tests, scans and referrals to services such as infectious diseases when it was deemed necessary and was kept informed of these treatments throughout.

50. Our adviser also says communication throughout Miss X’s care between her and the Trust was reasonable and she was regularly updated on her condition. We cannot see there would have been a reason why Miss X would have needed to wait until she was told she had arachnoiditis before considering taking legal action if she was unhappy with her care.

51. Based on the evidence, we consider Miss X was given an update on her open biopsy in line with GMC guidance on sharing information and consider the Trust kept Miss X reasonably informed throughout her treatment. We consider the Trust has given the correct care and treatment to Miss X. We understand this must have been a stressful and emotional time for Miss X, and we appreciate she wanted to be kept as involved as possible in her case.

52. We do not see a gap between what should have happened and what did happen in relation to this complaint and therefore do not see a maladministration or service error.

53. For these reasons we will not consider this issue further.

Conclusion

54. We recognise this complaint and the circumstances around it have caused Miss X considerable distress and worry. We hope our report reassures Miss X appropriate action has been taken to address her concerns.

55. We thank Miss X for bringing her complaint to us and allowing us to consider this complaint.

1. We have carefully considered Miss X’s complaint about an independent provider in the Sheffield area (the Hospital) and Sheffield Teaching Hospitals NHS Foundation Trust (the Trust).

2. Miss X says between October 2021, and February 2022 the Hospital failed to give her the appropriate care and treatment despite pain after her microdiscectomy.

3. Miss X says the Trust failed to inform her of any findings after her open-biopsy and she was not given a diagnosis of arachnoiditis until after the legal threshold. She further complains in August 2022 a CT guided biopsy was incorrectly carried out whilst she was awake.

4. We sincerely appreciate this was a distressing time for Miss X. We hope this statement gives Miss X reassurance we have thoroughly considered her concerns. We are grateful for the time and effort Miss X made in bringing her complaint to our attention.

5. We would like to assure Miss X for all areas of her complaint we have not seen indications the care and treatment she received from the Trust and the Hospital amounted to a failing.

6. In making our decision, we do not intend to diminish how stressful this time was for Miss X.