Decision Report 201508011

Summary

Mrs C complained that staff at the minor injuries clinic (MIC) at the Western General Hospital failed to identify that her ankle was broken. She also complained that as part of the board's investigation, the staff member involved gave false information about the advice given to Mrs C when she attended the MIC. Mrs C stated she was advised she could travel while the board stated she was advised travel was not ideal.

We took independent advice from a consultant in emergency medicine. While we found that Mrs C's ankle fracture had been missed when she attended the MIC, the advice we received was that the fracture had not been obvious and it was understandable that it had been missed. However, we were concerned that when the radiologist's report identified the fracture, the board did not contact Mrs C in line with their procedures. We were also concerned that the board failed to explain the reason for the failure in their system in this case. We therefore upheld this part of the complaint and made several recommendations to address the failings we found.

We found no objective evidence to prove or disprove what advice about travel had been given to Mrs C when she attended the MIC. We did not uphold this part of the complaint.

Recommendations

We recommended that the board:

• provide further information on the system in place for reviewing MIC x-ray reports, correlating them to the interpretation and diagnosis by the practitioner and the system for acting on any missed injuries;
• provide further information on how any missed injuries are recorded and audited;
• bring the adviser's comments on the advice to give patients with soft tissue injuries to the attention of the relevant physiotherapy practitioner; and
• ensure that the physiotherapy practitioner involved in this case is reminded of the requirement to make accurate records of advice given to patients and specifically document any advice given with regards to fitness to travel.