Decision Report 201305701

Summary

Mr C complained that staff at the Royal Alexandra Hospital, Paisley failed to adequately assess his symptoms following a jarring injury to his neck from a fall in his garden. Mr C raised a number of concerns, including that the doctor who saw him failed to take adequate account of his dystonia (a movement disorder that causes muscle spasms and contractions), failed to arrange an x-ray and failed to ensure he had adequate pain relief. Mr C said it was later identified that his neck was fractured, but said that by then it was too late for it to be treated.

We took independent medical advice from a consultant in emergency medicine. The board indicated that the doctor's assessment of Mr C was appropriate. However, as the board could not locate Mr C's medical records, we could not clearly determine that this was the case. We were very critical of the board's management of Mr C's records.

Our adviser said that in general Mr C's dystonia would have played no part in his assessment and the determination of the treatment he required. However, he said that the doctor who saw Mr C should have considered the impact of his dystonia on his ability to swallow when determining appropriate pain relief. In the absence of a pain score, it was difficult to determine exactly what level of pain relief should have been provided. However, the board acknowledged that their understanding of the medication available to Mr C at home was incorrect and it would appear that Mr C was, therefore, sent home without adequate pain relief.

Further, given Mr C's swallowing problems caused by his dystonia, our adviser said that he would have expected senior involvement in deciding if Mr C should have been admitted for pain relief and we were critical of the board for failing to arrange this.

In terms of the need for an x-ray, the adviser was clear that, given the absence of any direct blow to Mr C's head, an x-ray was not indicated.

Recommendations

We recommended that the board:

• review their practice on the storage of patients' medical records to ensure that records are stored securely in future.