• Case ref:
  • Date:
    June 2019
  • Body:
    Fife NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Upheld, recommendations


Miss C suffered from chronic osteoarthritis (a common form of arthritis that leads to pain, stiffness and swelling of the joints) in both of her hips and asked her GP to refer her to a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system) to be considered for hip replacement surgery. The consultant advised that they would not consider Miss C for surgery until her Body Mass Index (BMI, a measure for estimating human body fat) was reduced to an appropriate level. Miss C complained to the board that the consultant wrongly focused solely on her BMI and did not properly examine her or discuss her pain and mobility issues. Miss C requested a private referral for surgery from her GP and underwent hip replacement surgery on both of her hips.

The board explained that the consultant did not physically examine Miss C as there was no clinical reason to do so and that there are considerable risks and increased complication in patients who undergo surgery with a BMI greater than 40. Therefore, surgery is not recommended.

We took independent advice from an orthopaedic surgeon. We found that the board's approach to dealing with referrals of patients with a high BMI for hip replacement surgery was not sufficiently supported by the available guidance and it did not allow for individualised treatment. We also found that the board failed to carry out a thorough clinical assessment and that their reason for not offering Miss C a second opinion was not in line with the relevant guidance. Therefore, we upheld the complaint.


What we asked the organisation to do in this case:

  • Apologise to Miss C for failing to carry out her hip replacement surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
  • Reimburse Miss C for the cost of her first private hip replacement surgery on receipt of proof of the cost. The payment should be made by the date indicated. If payment is not made by that date, interest should be paid at the standard rate of interest applied by the courts from that date to the date of payment.

What we said should change to put things right in future:

  • The board should ensure that their approach in dealing with referrals of patients with a high BMI is flexible, in line with available guidance and adopts a holistic approach when deciding whether to carry out surgery.
  • The board should ensure that patients with a high BMI who are seeking surgery are fully assessed.
  • The board should remind staff of the General Medical Council guidance on consent and emphasise that the offer of a second opinion should not be limited to those occasions when the doctor is considering to offer treatment that they would not ordinarily do so.
  • The board should ensure GP practices within their area are aware that patients can be re-referred if there is deterioration in their condition.