Trust did not resolve a woman's chronic shoulder pain although it carried out two operations

What happened

Ms A had a history of shoulder problems and had already had surgery on both shoulders in 2008. In late 2011, her GP referred her to the Trust's shoulder unit because she had pain when she moved her left shoulder. She was seen by a consultant orthopaedic surgeon and had surgery in winter 2011.

Ms A later had a follow‑up outpatient appointment and six sessions of physiotherapy. However, she continued to experience pain.

Ms A went back to her GP in early 2012 and, after various attempts (including private therapy) to relieve the symptoms were unsuccessful, she was referred back to the shoulder unit. She had a second operation on her left shoulder in summer 2012.

After three further physiotherapy sessions, Ms A's pain persisted, so she asked the Trust for a second opinion from another orthopaedic surgeon. Ms A later had a third operation on her shoulder in autumn 2012. Further physiotherapy relieved her pain and symptoms.

What we found

Although Ms A's consultant correctly assessed her condition and arranged the investigations she needed, her doctors did not single out whether the problem was due to her shoulder joint or inflammation of the tendon due to calcium deposits.

Significantly, they did not give her an important diagnostic injection that Ms A's consultant had recommended. This meant that clinical decisions about Ms A's first and second operations were not based on all the relevant information. Also, Ms A's follow‑up care after her first and second operations was not well organised.

Although Ms A's first operation included surgery to the joint at the tip of her shoulder, the surgeon did not focus completely on this joint. If he had, Ms A's surgery may have solved the problem the first time.

As it was, when Ms A had a second operation, doctors incorrectly concentrated on removing the calcium on the tendon, which meant that the operation did not deal with the underlying cause of her symptoms (the joint at the tip of her shoulder). So a third operation was needed, with the extra pain and discomfort that caused. And, because Ms A's follow‑up care had not been well organised, Ms A experienced more distress.

Putting it right

The Trust apologised to Ms A for its failings and agreed to put together an action plan that showed that it had learnt from its mistakes so that they would not happen again. The Trust also paid Ms A £2,000 compensation and reimbursed her over £500 for the private treatment she had had for her pain.