Decision Report 201301205

Summary

After Mr C fell downstairs, he was admitted to a local hospital, where a scan did not show any fractures. However, the next morning he had no feeling in his legs and he was transferred to a second hospital, where a consultant interpreted a further emergency scan as showing only degenerative changes in his spine. Mr C was later referred elsewhere, where he was finally diagnosed with an undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) of his spine. He now has to use a wheelchair.

His wife (Mrs C) complained about Mr C's care and treatment at the second hospital. She was concerned that he had not been handled and moved appropriately and that this could have affected the outcome for him. She was unhappy that his undisplaced fracture had not been diagnosed and that he was not kept lying down and in a neck brace.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Mr C's medical records. We also obtained independent advice from two of our medical advisers, a consultant neurosurgeon and a consultant diagnostic and interventional neuroradiologist. The advice received confirmed that the board missed an undisplaced fracture of a vertebra (a bone of the spine) which should have been detected when interpreting the scan in the second hospital. The adviser commented that, despite this, Mr C had been managed as if he had had a spinal injury. The adviser said, however, that the damage to Mr C's spine had already occurred before he was admitted to the second hospital and that the treatment would not have affected Mr C's outcome. We upheld Mrs C's complaint, but as the board had already admitted that there were failures in the way they cared for and treated Mr C, and had taken action to address this, we did not find it necessary to make any recommendations.