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Decision report 201200621

  • Case ref:
    201200621
  • Date:
    April 2013
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C fractured his leg in several places. He was admitted to hospital and had an operation. The consultant reviewed Mr C the next day. Mr C had a change of plaster cast and was advised not to put weight on his leg. Mr C's medical records noted the following day that he was not complying with the non-weight bearing instructions. He was discharged several days later.

Mr C's first out-patient appointment early the next month was cancelled and he was seen towards the end of that month. An x-ray taken at that appointment showed that the tibia (large bone in the leg) was misaligned. The board told Mr C that the consultant's opinion was that the misalignment was likely to have been the result of Mr C bearing weight on his leg contrary to advice. Mr C told us that this unreasonably blamed him for problems with his leg. Mr C sought an acknowledgement that things went wrong during his operation and an apology from the board. He said that as a result of the board’s failures, he will suffer pain permanently.

Our investigation included taking independent advice from one of our medical advisers. We found that the operation was performed to a reasonable standard and that it was likely that a number of factors, including the severity of the fracture, led to the misalignment. Mr C was concerned about the misalignment, but the advice we received and accepted is that it was within reasonable limits. We also found evidence in Mr C's medical records that he was not complying with the advice to put weight on his leg, and we were satisfied that the board's response reflected what was in these records. We appreciated why Mr C was unhappy with the way in which the board's first response was worded, but found that they had later assured him that they were not accusing him of wrongdoing but, rather, had recognised that he could not comply fully.

Updated: March 13, 2018