Decision Report 201503407

Summary

Mr C complained to the board about the treatment they offered him for an injury he suffered to his knee. He had originally attended a GP at the prison health centre and received an x-ray which showed no problems. It was therefore decided that he should attempt physiotherapy and return if the pain persisted. However, when he requested a further appointment to see the GP because he felt he should have a scan, his request was triaged by a nurse who advised that as his x-ray had been normal, he did not need an appointment or a scan.

We took independent advice from two advisers, one a GP and one a nurse. We found that Mr C's records showed that after the x-ray, his GP mentioned that a scan may be required if problems persisted. The advisers confirmed that the nurse in question should have consulted a GP and that, in line with national guidelines for the management of knee pain, further investigation would have been appropriate in the circumstances. As such, we upheld the complaint.

Recommendations

We recommended that the board:

• bring the failings to the attention of relevant staff;
• review their clinical decision-making in light of the relevant guideline;
• review the triage system to ensure that decision-making is made appropriately within the clinician's scope of expertise;
• apologise to Mr C for the failings identified; and
• arrange for a further GP assessment of Mr C's knee, if this has not happened already.