Decision Report 201402874

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury.

Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Recommendations

We recommended that the board:

• remind staff in the minor injuries and illnesses unit of the 'Tayside Hand Unit – Trauma Referral Guidelines' (in particular the guidance on assessment of wounds on page 7);
• consider options for improving the tracking of similar referrals in the general medical clinic;
• bring our findings to the attention of relevant staff for reflection and learning;
• issue a sincere written apology to Mrs A, acknowledging the failings our investigation found; and
• remind relevant staff of the need to ensure complaints are fully investigated in line with the complaints procedure and the responses provide full explanations of the matters raised.