Decision Report 201400621

Summary

Mrs C was suffering from pain in her thigh some time after having a hip replacement, and her GP referred her for an x-ray. The report of the x-ray noted that there was no abnormality, but that there were also no previous images available for comparison as Mrs C's earlier x-rays were taken in another NHS board area. Mrs C was later seen by a private doctor who considered that the x-ray did show an abnormality that needed investigation. Further x-rays showed a problem with the replacement hip and a possible fracture, and Mrs C needed two more operations to fix this.

She complained that the board had failed to identify the abnormality in her

x-ray. The board took the view that the x-ray did show a subtle abnormality, but that without previous images to compare this to, it was difficult to tell if it was significant. They explained that a new system had since been introduced which made it easier to view x-rays taken elsewhere in Scotland.

After taking independent advice from one of our medical advisers, who is a consultant in radiology, we upheld Mrs C's complaint. The adviser reviewed Mrs C's x-ray and took the view that whilst the abnormality was relatively subtle, it was visible and could have been considered potentially significant for Mrs C. The adviser explained that it would have been appropriate to refer Mrs C for further investigations on the basis of the x-ray.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure to identify and report the abnormality in her x-ray; and
• provide a copy of our decision letter to the reporting doctor to allow him to reflect on Mrs C's case and discuss any learning points at his next appraisal.