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Case ref:201701774
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Date:August 2018
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Body:Lanarkshire NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about the care and treatment he received at Wishaw General Hospital (WGH) when he attended the emergency department after falling at home and injuring his lower back. Mr C was concerned that he was discharged home without having had an x-ray. He was also dissatisfied about the in-patient hospital care he received after being admitted to hospital two days later at which time an x-ray confirmed a spinal fracture. Mr C was unhappy about delays in transferring him to a different hospital spinal unit and being informed that he had a second spinal fracture.
We took independent advice from a consultant in emergency medicine and a consultant orthopaedic surgeon (a specialist concerned with the musculoskeletal system). In relation to the care Mr C received in the emergency department, we considered that the decision not to do an x-ray and the delay in diagnosis were reasonable given that a number of factors made this type of injury unlikely in Mr C's case. Therefore, we did not uphold this aspect of Mr C's complaint.
In relation to the orthopaedic care received, the board acknowledged that it would have been appropriate to have discussed Mr C's case again with the spinal unit of another hospital. We found that there was a lack of communication with Mr C in relation to his second fracture and that a more senior discussion with the spinal unit may have led to more timely transfer. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that these issues were unlikely to have influenced his subsequent treatment.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for the failings in communication regarding his second fracture. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- Patients should be informed of relevant test results and this should be fully documented in the medical records.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.