Decision report 201105502

Summary

Mr C fell from his bicycle at speed and landed on his head. His GP was concerned that he might have suffered a spinal injury and arranged for him to go to hospital. Mr C was x-rayed, and discharged with a diagnosis of a soft tissue neck injury. Three days later, the hospital contacted Mr C, saying that, following a re-examination of his x-ray, it was possible that he had a cracked rib. Mr C went back to the hospital where he was given scans that confirmed the cracked rib and also identified cracked vertebrae. Mr C was fitted with a neck collar.

Mr C complained that there was a failure to carry out an appropriate assessment at the hospital when he first attended and that he was discharged home without a neck support. He also complained that when he next attended the hospital there was a delay in providing him with a neck collar once the fractured vertebrae had been confirmed. Having looked at the medical records and taken independent advice from our medical adviser, we found that the cracked rib should have been identified from the x-ray when Mr C first attended hospital. We upheld that complaint and made recommendations to address this. However, we did not uphold his other complaint, as our investigation found that the remainder of his care and treatment was appropriate.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to identify his rib fracture; and
• review the arrangements in place for assessing x-rays and remind relevant staff that attention must be paid to all information on the film including information outside the focus of the subject of the x-ray.