Decision report 201100319

Summary
Mr C attended the A&E department at Glasgow Royal Infirmary after a fall. He complained of severe back pain but a full skeletal x-ray was not carried out in A&E or on admission to an orthopaedic ward. Mr C was told a back x-ray was scheduled for two days' time and he could go home until then. Mr C's wife (Mrs C) reported her concerns about the proposed discharge to the consultant, who, after examining Mr C, said that an x-ray was not required and that Mr C could go home immediately.

Around two weeks later, Mr C attended the Glasgow Royal Infirmary Fracture Clinic and following an x-ray of his spine was admitted. He was examined the next day and it was decided to transfer Mr C to Spinal Injuries Intensive Care Unit at Glasgow Southern General Hospital where he was operated on for a broken back and complications with his right leg. Mrs C wished to know why the spinal injury was not picked up at Glasgow Royal Infirmary.
We found that on arrival at A&E, Mr C should have been placed flat on a spinal injury board and then examined by log-rolling to keep him immobilised but that this did not happen. We also found that staff failed to consider whether Mr C had sustained injuries elsewhere in his body and that there was a breakdown in communication between nursing and medical staff.

Although we upheld Mr C's complaint, we made no recommendations as the board had taken steps to prevent a similar situation occurring again and apologised for the failings which had been identified.