Surgical error caused unnecessary pain, scarring and avoidable second surgery

Organisation we investigated: Manchester University NHS Foundation Trust

Date investigation closed: October 2018

The complaint

Mr T complained about surgery he had at Manchester University NHS Foundation Trust in December 2016.

He said a lipoma, which is a benign tumour, was not removed during surgery as originally planned. As a result he suffered from nine months of unnecessary pain and scarring and had to undergo an avoidable second operation.


In July 2016, Mr T visited his GP complaining of pain in his back. Following this, his GP sent a letter to the Trust’s general surgery department about Mr T needing surgery to remove two lipomas – one from his left leg and one from the left side of his back.

The surgery took place in December 2016 and tissue was removed from Mr T’s left leg and back under local anaesthetic. The Trust’s surgeon had made an incision below the lipoma on Mr T’s back rather than over it as is the usual procedure. The Trust explained that an ‘irregular piece of fatty tissue’ was removed and histology reports confirmed it was a lipoma.

In February 2017, Mr T visited his GP who told him that the lipoma in his back had not been removed. His GP wrote to the Trust informing them of this and Mr T had a second operation in September 2017 when the lipoma on his back was successfully removed.

What we found

We fully upheld this complaint. We found that on the balance of probability, during the first operation the Trust’s surgeon did not make the incision in the correct place on Mr T’s back and did not remove this lipoma. During the second operation, the surgeon made an incision over the lipoma, as is the usual procedure, and successfully removed it. If the incision made below the lipoma during the first operation was in the correct place, this incision would have been re-opened. We found no evidence to suggest that the original incision should have been made where it was. This meant that Mr T was left with an additional scar due to an unnecessary operation and this indicated a failing on behalf of the Trust.

Mr T suffered pain from the lipoma while he was waiting for the second operation to have it removed. The Trust said that it was not possible to confirm whether or not his pain was caused by the lipoma remaining in his back or if it was because it had grown back. Our clinical adviser said that, had the lipoma been removed as the Trust claimed, it would not be reasonable for another to grow back in its place so quickly.

Our clinical adviser said the histology report showed that the Trust was not certain that the tissue removed during the first operation was a lipoma.

We found that Mr T suffered avoidable pain from an operation that would not have been necessary if the failing hadn’t occurred. Mr T also suffered from avoidable pain for an additional nine months from the lipoma itself and has an additional scar on the left side of his body. We also recognised how the failings may have caused Mr T some stress and loss of faith in the NHS.

Putting it right

Following our recommendation, the Trust wrote to acknowledge and formally apologise to Mr T for the failings in his care and treatment. The Trust also paid him £1,000 in recognition of the unnecessary pain and stress caused as a result of the failings identified in our report.