Decision Report 201301375

Summary

Mr C was admitted to a hospital accident and emergency (A&E) department after falling down stairs. On arrival his neck was immobilised in a collar, and it was noted that he had movement in his arms and legs with sensation in all his limbs. However, it was also noted that there were problems with his cooperation during this examination. A scan showed no acute fracture or bleeding and Mr C's neck collar was removed. The next morning, Mr C was found to have lost the power in his legs and he was transferred urgently to another hospital for treatment. His wife (Mrs C) complained that, given his accident, Mr C should have been kept immobile and given a full spinal scan. She also believed that proper tests were not carried out to determine the extent of his injuries and that he should have been transferred immediately to a specialist unit.

To investigate the complaint, we carefully considered all the relevant information, including all the complaints correspondence and Mr C's medical records. We also obtained independent advice from a consultant in emergency medicine and took this into account. Our investigation found that although Mr C was immediately immobilised on his admission to A&E, his neck collar was removed despite recorded difficulties in completing an assessment. Relevant advanced trauma life support (ATLS) guidelines suggested that Mr C should have remained in the collar until he was determined to be neurologically normal and could have been properly assessed. We upheld the complaint that Mr C should have been kept immobile, but did not uphold the others as our investigation found that all appropriate tests were carried out to establish the extent of his injuries and that the proper protocol was followed in transferring him to another hospital, rather than to a specialist unit.

Recommendations

We recommended that the board:

• apologise to Mr C for removing the hard collar before he was confirmed to be neurologically normal; and
• take appropriate steps to satisfy themselves that, with regard to evaluation, ATLS guidelines are fully complied with.