Manchester Spinal Surgery Patient Safety Review Published

In late July 2023, the Northern Care Alliance published the report of its “Look Back Review” of spinal surgery patient safety, arising from care provided to its patients by one of its spinal surgeons (Surgeon A) between 2009 and 2015.  

Background to the review  

Investigations into Surgeon A’s conduct were initiated following concerns raised in 2014 by an anonymous whistle-blower who drew attention to poor surgical outcomes and, it seems, concerns around professional conduct within the hospital. The report focuses on a review of Surgeon A’s practice between August 2009 and September 2014. Surgeon A was dismissed from the Trust in 2015.   

130 patients were considered in this review. However, it seems probable that there are more patients who may have been affected by Surgeon A who were treated in other hospitals or who have been lost to follow up.  

The review focused on a few key areas of patient care, including: 

• inaccuracy of medical record keeping,  
• inadequate processes of obtaining and recording informed consent,  
• lack of openness when things went wrong, and  
• concerns with the standard of surgical technique when operating on patients’ spines. 

A spinal surgeon from another NHS Trust was recruited to provide an independent external expert review of the records. He found that Surgeon A’s surgical practise was judged to be poor in multiple cases and he specifically found issues with the placement of metalwork in and around the spine in a high number of cases. 

In many cases surgery was found to be poorly planned, and patients suffered high levels of blood loss for the surgery performed. It was also found that Surgeon A incorrectly applied paediatric surgical practises and concepts to more complex adult surgical patients. 

When considering the potential impact on patient outcomes as a consequence of Surgeon A’s practise, the report found that a number had suffered “severe harm”. 

Inaccurate and inconsistent record-keeping 

Another worrying finding was that in a “high number of cases” patient documentation was not only poor but was found to be inaccurate or inconsistent with other records completed by other healthcare professionals managing these patients. 

Patient autonomy and the importance of patients being provided with proper information to enable them to give informed consent to undergoing surgical procedures is not a new concept in medicine. It is deeply concerning that the review found that “compliance with informed consent processes was found to be poor in a high number of cases.” 

In some cases, the risks documented on the consent form and associated documentation did not reflect those of the proposed surgery. It was also noted that a number of consent forms featured the same risks despite the variation in the proposed surgery. This was also evidenced following discussions with patients during the course of the review. 

There has, for a long time, been a recognition in medicine that it is important for clinicians to be open with patients when things go wrong. In fact, there is now a statutory “Duty of Candour” requiring such openness. 

Although these cases predate the introduction of this statutory Duty of Candour, the requirement to be open with patients has featured in the GMC Good Practise Guide for many years. The review identified failings in being open and honest with patients in a high number of cases. 

The delay an undertaking this review is of concern, but it may stem from misplaced reassurance following an earlier review. The report notes that the Royal College of Surgeons had undertaken its own review of a sample of 10 of Surgeon A’s patients in 2015. The Royal College of Surgeons reported the following year that,  

“…there were no overall concerns about the standard of care provided to the patients that formed part of the review, although a series of complications were acknowledged. From the information present in the clinical records it appears that the way in which the complications were managed once identified was appropriate in each case.” 

It is significant that the independent expert reviewing these cases reached a different conclusion from that of the Royal College of Surgeons review in the majority of those cases.  The report recommends that the Trust should share its findings with the Royal College of Surgeons for comment and appropriate action. 

Action Plan and Implementations 

The report concludes by setting out an action plan with a timetable and it is pleasing to see that, while there is more work to be done, a number of those recommendations have been implemented. 

However, the report also identified that there were a number of patients of Surgeon A who were either treated in the private sector or at Manchester Children’s Hospital.  These cases were not included in this review and it appears that separate reviews are being undertaken at those institutions.   

It is important that they report openly and without delay. 

Legal support after life-changing injuries 

Whilst the findings of this review are obviously a cause for concern, it does seem that steps have been put in place and will be put in place to reduce the risk of such issues arising again.  

Ultimately, this report is aimed at improving patient safety and thus the best outcome from these reviews is that clinical staff learn from the identified shortcomings (whether they were involved in these cases or not) and reflect upon and improve their own practice where necessary to ensure that these events are not repeated in the future. 

It is far better that patients do not come to harm in the first place rather than finding themselves having to seek legal advice when things go wrong. 

Time will tell if lessons have been learnt. 

Over the years I have handled many spinal injury claims arising from medical negligence and so when reviewing this report, I was particularly interested to understand the detail of some of the specific concerns with the delivery of patient care that were identified.  

It is disappointing that a report which has a central theme of openness seems currently only to be available through the Northern Care Alliance website in a redacted form which has had that specific detail removed.  It would be surprising if this information could not be provided in a form that would protect patient confidentiality and I hope to see a full and open report published in due course.