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Case ref:201502853
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Date:May 2016
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C complained on behalf of her son (Mr A) about the severe toe pain he suffered since undergoing a total nail avulsion (complete removal of the toenail) in 2013. Mr A had been seen by podiatry staff on a number of occasions following the surgery. As a result of the severe pain, Mrs C said that Mr A had lost his confidence and been unable to undertake his usual activities. Mrs C was concerned that a number of investigations, tests and referrals appeared to be undertaken only when she complained to the board two years after the initial surgery.
We took independent advice from a medical adviser. They said that the treatment decisions were reasonable in light of the main post-operative complications associated with a nail avulsion. However, while the initial referrals, tests and investigations appeared to be carried out within a reasonable time, repeating the surgical and other investigations when previous investigations had not provided a diagnosis to the problem delayed referral onto a specialist pain team. We found this to be unreasonable, so we upheld Mrs C's complaint.
Recommendations
We recommended that the board:
- review their processes to ensure referrals to specialised pain teams are made within a reasonable time;
- bring our decision including the adviser's comments to the attention of relevant staff; and
- apologise for the failures our investigation identified.