Decision Report 201404472

Summary

Mr C complained about the treatment his father (Mr A) received from the board. Mr A had had a history of Parkinson’s disease, dementia and type 1 diabetes. However, Mr A controlled his diabetes well and lived independently before having a fall. He was admitted to Hairmyres Hospital with hip pain and reduced mobility. X-rays showed no sign of a fracture, but Mr A was kept in hospital due to his poor mobility. His pain and mobility worsened, and a second x-ray was taken around four weeks later. This showed a displaced fracture in his hip. Mr C complained that his father’s diabetes was poorly managed during his admission, causing increased confusion and unsafe blood sugar levels. He also complained about a delay to the second x-ray and the diagnosis of Mr A’s fracture.

We took independent advice from a nursing adviser, and found that the nursing staff failed to properly manage Mr A’s diabetes. The board had already identified failings in this respect and we were satisfied that they had learned lessons from Mr A’s experiences.

We also took independent advice regarding the diagnosis of Mr A’s hip fracture from a consultant in orthopaedic and trauma surgery and a consultant physiotherapist specialising in orthopaedics (relating to the musculoskeletal system). Whilst there was no visible sign of the fracture on the first x-rays, Mr A's pain and mobility did not improve. We concluded that, in line with national guidance, further x-rays or scans should have been ordered to rule out a fracture. There was a clear delay to this happening and, by the time of the second x-ray, the fracture had displaced. This required a more invasive operation than would have been needed had the fracture been diagnosed before it displaced. We were critical of the board for this delayed diagnosis.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's performance in terms of effectively managing diabetic patients' insulin regimes to gauge the effectiveness of action taken in response to Mr C's complaint;
• apologise to Mr A and his family for the delay in diagnosing his fractured hip;
• share our decision with their orthopaedic staff with a view to learning from Mr A's experiences; and
• consider whether orthopaedic staff would benefit from refresher training on the national guidance on treating hip fractures in elderly patients.