Decision Report 201604509

Summary

Ms C complained about the care and treatment provided by the physiotherapy service at Stonehouse Hospital, and that a scan had not been recommended despite her severe back pain.

We took independent physiotherapy advice and found that the initial assessment carried out was inadequate and had not followed the board's local guidance on lower back pain. We upheld this aspect of the complaint and made a number of recommendations to address these failings.

Whilst we found that a scan would not have been appropriate, we were critical that the reasons for this were not clearly explained to Ms C. We did not uphold this aspect of the complaint, but made a recommendation to address the lack of record-keeping in this respect.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in this investigation.

What we said should change to put things right in future:

• The physiotherapist should be reminded about the importance of good record-keeping which should include a detailed history and comprehensive discussions with the patient.
• Conduct a review of current local physiotherapy assessment management of chronic low back pain alongside the board's local low back pain guidance and national guidance.
• Draw the findings of this report to the attention of the physiotherapist involved.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.