C complained about the care and treatment provided to their spouse (A). A developed Cauda Equina Syndrome (CES, narrowing of the spinal column where all of the nerves in the lower back suddenly become severely compressed) in September 2018. C believed there were avoidable delays in diagnosing and treating A, which meant the damage A suffered was more severe and the outcome worse than it might have been.
A was originally referred to Royal Alexandra Hospital (Hospital 1) by their General Practitioner (GP). C believed that A was displaying red flag symptoms of CES at this point. A attended Hospital 1 on 20 September 2018, but was discharged without consultant review or imaging of their spine.
A continued to deteriorate and attended Hospital 1 again on 28 September 2018 at 09:00 hrs. A Magnetic Resonance Imaging (MRI) scan (a scan using power magnetic fields to generate images of the inside of the body) was carried out at 15:00 hrs. The neurosurgical team at Queen Elizabeth University Hospital (Hospital 2) were contacted, but they declined to accept A for transfer. A was discharged at around 21:00 hrs. They did not have a treatment plan and had not been reviewed by a consultant.
C took A to Hospital 2's A&E the following day. A was admitted to a neurosurgery ward and reviewed by a junior doctor. On 30 September 2018, A was referred for a further MRI by the Consultant Neurosurgeon. A underwent surgery on 1 October 2018.
A was discharged without any follow-up care being arranged. This was later arranged by their GP. They were admitted a month later as a spinal emergency, and again A was discharged without any follow-up care being arranged.
Relevant to this report was case 2016084301; a public report we issued about the Board previously. This investigation looked into a complaint of unreasonable delays in the treatment of CES by the Board. The investigation found that the Board failed to provide spinal surgery in a reasonable timeframe to the complainant. This was despite clear guidance that surgery needed to be performed as an emergency on an incomplete CES. This also included a failure to provide the complainant with adequate information about their condition or make the necessary referrals for postoperative care.
This report was published in January 2018. The case was closed after the Board provided evidence it had complied with our recommendations, which was largely done by April 2018. This is significant, because A's first attendance at hospital was in September 2018, after the Board was meant to have implemented changes to reduce delays for patients with CES.
We took independent advice from a consultant orthopaedic surgeon and a consultant neurosurgeon. Both advisers identified avoidable delays in A's care and treatment. The orthopaedic adviser said that A had been displaying red flag symptoms of CES when they first attended hospital on 20 September 2018. The delays in scanning A were unreasonable and A's treatment had not been in line with national guidance on the management of possible CES cases.
The neurosurgery adviser said that it was unreasonable for the Neurosurgery Department at Hospital 2 to refuse to provide diagnostic advice, or accept A for transfer on 28 September 2018. A should have been admitted as a neurosurgical emergency and undergone decompression surgery on 28 September 2018. It was also unreasonable to have delayed A's surgery further once they were admitted to a neurosurgical ward.
We found that there were significant failings by the Board in the care and treatment that was provided to A. These included the failure to recognise that A was displaying red flag symptoms of CES, unreasonable delays and incorrect decisions to discharge A, as well as avoidable delays to performing surgery on A, once the severity of their condition had been grasped.
We also found that the Board had failed to investigate C's complaint appropriately or adequately. The Board did not appear to be aware of Public Report 201608430, even though it was closely related to the issues raised by C in this case, and the Board had previously confirmed they had taken action to address the failings identified in that report.
We considered that this case raised significant concerns, given the failings in care and the failure by the Board to identify these, despite their lengthy complaint investigation. This took place within months of the Board having provided this office with assurances that they had taken action to improve the identification and treatment of patients with CES symptoms.
We upheld all of C's complaints.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for C and A:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
a) |
A's care for CES was not in line with the appropriate standards |
Apologise to C and A for failing to provide care for A in line with the appropriate standards. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets |
A copy or evidence of the apology. By: 19 June 2021 |
|
b) |
The Board's actions resulted in an unreasonable delay in admitting and treating A |
Apologise to A for the unreasonable delay in admitting and treating them. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets |
A copy or evidence of the apology. By: 19 June 2021 |
|
c) |
The Board have not explained why A was discharged on 28 September 2018 |
Apologise to C and A for failing to provide an adequate explanation for the decision to discharge A. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets |
A copy or evidence of the apology. By: 19 June 2021 |
|
d) |
The Board failed to refer A to the appropriate specialisms for ongoing care, resulting in further delays to their treatment |
Apologise to C and A for failing to refer A to the appropriate specialisms for ongoing care resulting in further delays to their treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets |
A copy or evidence of the apology. By: 19 June 2021 |
|
e) |
The Board failed to handle C's complaint reasonably |
Apologise to C and A for failing to handle their complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets |
A copy or evidence of the apology. By: 19 June 2021 |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
a), b) and c) |
A's incomplete CES was not recognised as a neurosurgical emergency |
Relevant staff understand the standard operating procedure, based on the British Association of Spine Surgeons guidelines for the care and management of CES, and provide appropriate treatment in line with it |
Evidence of staff knowledge of the standard operating procedure, including guidance for staff and an explanation of how its application will be monitored. By: 19 July 2021 |
|
a), b) and c) |
A's referral from the Orthopaedic Department to the Neurosurgery Department was not fully documented |
Document referrals to the Neurosurgery Department accurately and comprehensively by medical staff in the Orthopaedic Department |
Evidence the Board are monitoring the documentation of referrals to ensure they are comprehensive and accurate. By: reporting monthly for the next six months |
|
a), b) and c) |
Orthopaedic staff were unclear what to do when A's referral to Neurosurgery was refused |
Orthopaedic staff should have a clear procedure to follow when a referral is declined by the Neurosurgery Department |
Evidence of a clear procedures, including an explanation of how the Orthopaedic and Neurosurgery Department have collaborated in its creation. By: 19 August 2021 |
|
a) and b) |
A's surgery was unreasonably delayed |
Surgery for CES must be performed within recommended timescales |
The Board must evidence they have systems in place to ensure that patients are operated on within reasonable timescales and that these are being monitored on a monthly basis for the next twelve months. By: 19 June 2021 |
|
d) |
No referrals or aftercare arrangements were made for A |
Discharge should be planned with prompt referral to appropriate services. The Board should ensure that patients have the appropriate referrals made to community based services to support their care on discharge from hospital. This should include the transfer of care plans with the patient, where appropriate, to ensure continuity and consistency of care |
Evidence the Board have taken steps to address the difficulties in providing coordinated care for CES patients and that the effectiveness of these measures is monitored on a monthly basis. By: 19 June 2021 |
We are asking the Board to improve their complaints handling:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
|
e) |
The Board's complaint investigation failed to identify that treatment of CES by the Board had been the subject of a public report a matter of months before A's case |
To ensure the Board has effective complaint monitoring arrangements in place to identify when a new complaint concerns the same issues or clinical matters (CES in this case) as previous complaints, and that the relevance of outcomes and learning from previous cases are considered, as appropriate, in any new investigation |
Evidence the Board have effective complaint handling and monitoring systems in place. By: 19 August 2021 |
| e) | The Board's Morbidity and Mortality meeting was unreasonably delayed and did not involve all relevant staff | Morbidity and Mortality meetings should be held timeously and should involve representatives of all specialisms involved in a patient's care |
Evidence that Morbidity and Mortality procedures require the involvement of all relevant specialisms. By: 19 July 2021 |
| e) | The Board failed to properly implement their duty of candour | Appropriate implementation of the duty of candour, in line with General Medical Council guidance |
Evidence that the need to apply the duty of candour has been fed back to staff in the Orthopaedic and Neurosurgery teams in a supportive manner. By: 19 June 2021 |
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
|
a) |
The Board said they had already taken steps to ensure that patients with possible CES were not discharged without their case being discussed with an orthopaedic consultant first |
Provide evidence that it has been monitoring the effectiveness of these measures |
Evidence showing the procedural changes implemented by the Board, as well as the mechanisms in place for monitoring them. By: 19 June 2021 |