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Case ref:201808498
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Date:June 2020
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained to us on behalf of his late father (Mr A) who was diagnosed with, and subsequently died as a result of, septic arthritis (a serious type of joint infection). Mr C complained that the board failed to provide reasonable care and treatment in relation to Mr A's shoulder pain at a minor injuries unit (MIU) consultation and at a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) consultation. Mr C also complained that the board did not refer Mr A for x-ray or to orthopaedics (conditions involving the musculoskeletal system). Mr C considered that this had caused delays with Mr A being ultimately diagnosed with joint sepsis.
We took independent advice from an emergency nurse practitioner and from a consultant physiotherapist. We found that the board's consultations with Mr A were unreasonable in that Mr A should have been referred for an x-ray at the MIU consultation and that Mr A's presenting symptoms were not appropriately assessed at the physiotherapy consultation; it also had not been demonstrated that infection had been ruled out as a differential diagnosis. We found that Mr A should have been referred for further investigations/assessment at the physiotherapy consultation. Therefore, we upheld this complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologiseto Mr C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- Patients should be referred for x-ray as appropriate. Patients presenting for physiotherapy should be appropriately assessed in line with recommended clinical guidelines, taking in account their presenting symptoms, and this should be documented.
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.