Part 7 - Complaint about Cambridge University Hospitals NHS Foundation Trust (Cambridge) and Hinchingbrooke Health Care NHS Trust (Hinchingbrooke)
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Complaints about the assessment and management of an adolescent’s scoliosis; the post-operative care and treatment which led to his death; and the handling of complaints about those matters
Background to the complaint
In January 2000 Q, then aged 13, attended a combined Spinal Deformity Clinic at Cambridge (the Clinic), at which Mr M (Paediatric Orthopaedic Surgeon) and Mr H (Visiting Consultant Orthopaedic Surgeon from Hinchingbrooke) assessed children and adolescents with scoliosis (a spinal deformity). Q was assessed as having scoliosis and put on the waiting list for surgery. In January 2001 Q’s father, Mr R, asked if the operation could be carried out in early summer. Mr H explained that many parents wanted their children treated at a time that did not interfere with schooling, but he would do what he could.
In September 2001, shortly before the planned operation, Mr H belatedly reviewed an MRI scan taken in April, which had been filed away. The scan indicated a Syrinx (abnormal dilation of the central canal of the spinal cord). The surgery to correct that took priority over the scoliosis surgery, and was carried out at Cambridge in April 2002. The procedure markedly decreased Q’s neck mobility. It was noted that Q’s parents preferred the scoliosis care to be continued at Cambridge, but Mr M had no access to appropriate beds there.
Mr H and Mr M carried out the scoliosis surgery at Hinchingbrooke on 17 June 2003. Before the operation, the Consultant Anaesthetist at Hinchingbrooke (Dr Y) discussed with Dr P – the Consultant Anaesthetist and Intensive Care Unit (ICU) lead – the difficulty of placing a breathing tube in Q’s throat because of his rigid neck. It was decided to pass a flexible fibre optic scope through Q’s nose to visualise the opening of the windpipe and to pass a breathing tube over the scope and into his windpipe. That was accomplished and the operation went according to plan. Dr Y and Dr P decided to keep Q on a breathing machine for 24 to 48 hours after the surgery, by continuing to ventilate him through the nasal tube. After surgery Q was transferred to the ICU, where he was placed on volume controlled ventilation and received fluids. There were unexpected problems with Q’s care: he developed Adult Respiratory Distress Syndrome (ARDS – a severe form of acute lung injury) from which he did not recover. He lost fluids and his blood pressure dropped. A central venous pressure line was inserted and a tracheostomy was performed, allowing the nasal tube to be removed. Secretions on the tube from sinusitis cultured positive for MRSA. Steroids were started as treatment for the acute lung injury but Q’s condition continued to deteriorate. He died on 27 July, aged 17.
The complaint to the Trusts
In August 2003 Mr R asked both Trusts to review Q’s treatment to find out what had contributed to his son’s death. He also raised concerns, including the management of Q’s scoliosis and his care in the ICU. Hinchingbrooke’s report to Mr R contained explanations from the clinicians concerned. It concluded that Q’s ‘untimely death was not the result of a single or even several specific incidences of carelessness, neglect or inadequate care’. Cambridge apologised for the failure to either forward Q’s MRI scan results to Hinchingbrooke or for them to have been read and acted upon at Cambridge. Mr R’s subsequent request for an Independent Review was refused by the Convener, despite a Consultant Anaesthetist’s report identifying shortcomings in Q’s care and treatment in the ICU. Mr R complained to the Ombudsman in December 2004.
What we investigated
In terms of the assessment and management of Q’s scoliosis we investigated the following concerns:
- the nature of the scoliosis was not adequately assessed;
- investigations were not undertaken with sufficient promptness and regularity;
- there was a delay in reviewing the MRI scan;
- Q was not prioritised appropriately;
- there was no reassessment about where the scoliosis surgery should take place; and
- whether the organisation of the Clinic had any detrimental effect on Q’s assessment and surgical treatment.
On Q’s post-operative care and treatment we investigated:
- the management of ventilation and fluid volumes;
- the MRSA infection; and
- the standard of nursing care.
We also investigated the Trusts’ complaint handling.
In considering Mr R’s complaints, we sought advice from a Consultant Orthopaedic Surgeon, a Consultant Orthopaedic and Spinal Surgeon, a Consultant in Paediatric Intensive Care, a Consultant Anaesthetist and a Nurse Consultant in Critical Care. We also considered evidence provided by Mr and Mrs R at interview and in writing, the documents relating to the Trusts’ response to Mr R’s original complaint, relevant clinical records, and the testimony of Mr M and Mr H. We also discussed the management of Q’s anaesthesia and post-operative care with Dr Y and Dr P. We gathered information from the Trusts about planned changes to the Clinic and took account of the ‘British Scoliosis Society Guide to Practice’ (2001).
What our investigation found
Assessment and management of the scoliosis
There should have been a paediatric assessment for Q because of the length of time since his previous assessment (in 1995). Mr H now ensures that all younger patients go for paediatric assessment.
It was not common practice in 2000 to request an MRI scan of a scoliosis patient until surgery was clearly indicated, unless there were additional factors. In Q’s case there were no abnormal signs and surgery was not indicated until December 2000. Although it would have been best practice to order regular X-rays every six months, the length of time between X-rays (December 2000 and September 2001) was not unreasonable.
Clinicians must take responsibility for ensuring that test results are reviewed; in this case there was a failure to review an MRI scan promptly.
Mr H was limited to six sessions a year to undertake scoliosis surgery requiring two surgeons and was faced with conflicting demands from his patients. Problems with waiting times and prioritisation for scoliosis patients were not uncommon in 2000-01; therefore it was unreasonable to hold Mr H individually responsible for the pressures on the service.
Because of his rigid neck and the degree of spinal curvature, Q would have benefited had a multi-disciplinary pre-operative discussion taken place in order to assess the risks of the anaesthesia and the most appropriate site for scoliosis surgery.
The combined Clinic arrangements did not provide the necessary infrastructure to support all scoliosis patients referred to it. Adolescent scoliosis patients entering the Hinchingbrooke ‘stream’, such as Q, were disadvantaged because they did not access the advice and support of paediatric anaesthetists and paediatric intensive care staff that was available to Mr M’s patients.
Post-operative care and treatment
The management of Q’s post-operative ventilation was poor and, in all likelihood, had contributed to the damage to his lungs. The ventilatory parameters used immediately after surgery were too high for a patient of Q’s age and build, and the ventilation strategy used was not consistent with accepted practice in 2003. The management of Q’s fluid balance was deficient and the excessive fluid transfusion contributed to the rapid onset of ARDS. We were satisfied that MRSA did not contribute to Q’s deterioration and we found no deficiencies in the nursing care provided.
Complaint handling
The Trusts’ responses to Mr R’s original complaints were inadequate and did not answer his questions. Neither Chief Executive explained about the arrangements at the Clinic which led to some patients entering a different care pathway from other patients with similar clinical needs. Hinchingbrooke’s response to Mr R’s complaint was effectively provided by the clinicians concerned, and their failure to thoroughly review the factors which contributed to Q’s unexpected death was unacceptable. We were highly critical of the decision to refuse Mr R’s request for an Independent Review. While the ICU team undertook a clinical review of Q’s death, Hinchingbrooke did not take the opportunity to analyse the failings which contributed to the problems with Q’s care and treatment and to learn lessons.
We upheld most aspects of Mr R’s complaints. Individual and organisational failings resulted in the assessment and management of Q’s scoliosis falling below a reasonable standard. Although these shortcomings were unlikely to have impacted on the correction of the scoliosis, they led to unnecessary delays and increased discomfort and distress for Q. The organisation of the combined Clinic had a detrimental effect on Q’s assessment and surgical treatment, as Mr H’s patients did not have the benefit of the multi-disciplinary support and assessment available to Mr M’s patients. There were avoidable factors which led to the development of ARDS and Q’s subsequent death. Mr and Mrs R had a right to expect a thorough, joint investigation of the arrangements at the Clinic following the devastating loss of their child, but the Trusts’ responses to their complaints and concerns were inadequate.
Outcome
We made 14 recommendations aimed at bringing about systemic improvements to services for adolescents with scoliosis, and assisting both Trusts in addressing the very serious issues raised by our investigation. All our recommendations were accepted.
Both Trusts agreed that:
- each Chief Executive would send a letter of apology to Mr and Mrs R for the shortcomings identified and the failure to investigate their son’s death adequately; and provide them with details of the action taken in response to our recommendations and of the changes to the Spinal Deformity Service.
Among the recommendations we made to Hinchingbrooke were that they:
- revise their management of ventilation and fluids in intensive care and their management of intra-operative fluid balance during any major operation with risk of significant blood loss or prolonged surgery. In doing so, we recommended that they revisit the published research and rewrite their guidelines in line with current knowledge and expert opinion from the local Network and the Royal College of Anaesthetists; and
- ensure that the Chief Executive and the Medical Director receive assurance that current anaesthetic and ICU practice is safe and that they consider the further steps needed to understand the factors that contributed to Q’s death.
- provide evidence that the arrangements for the transfer of the results of investigations, correspondence and other records for Mr H’s patients from the Clinic to Hinchingbrooke have improved. In addition, both Trusts agreed to address the arrangements for pre-operative cardiopulmonary assessment.
Our recommendations to Cambridge included that they:
