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Case ref:201901318
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Date:August 2020
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Body:Highland NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / diagnosis
Summary
After injuring her finger, Mrs C was referred to the orthopaedic department. Her injury was reviewed on a number of occasions before being diagnosed as dislocated. A procedure was carried out to put the joint back into place. The pain in Mrs C’s finger did not improve, despite cast treatment and physiotherapy, so she was referred back to the orthopaedic department. After a further review, it became apparent that Mrs C had developed a complex regional pain syndrome (CRPS) in her right hand.
Mrs C complained to the board that there was an unreasonable delay in identifying that her finger was dislocated. She considered that the procedure to correct the dislocation should have happened sooner and, if it had, she would not have developed CRPS. She remained unhappy with the board’s response so brought her complaint to us.
We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there were a number of opportunities in Mrs C’s case for her dislocated finger to be identified earlier. We concluded that there was an unreasonable delay in reporting of the x-rays taken of her hand. We upheld Mrs C's complaint.
Recommendations
What we said should change to put things right in future:
- The board should ensure timely reporting of images to avoid delays as identified in Mrs C’s case in future.
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.