Decision Report 201707336

Summary

Mrs C complained that the board did not adequately investigate and treat the cause of her back pain.

We took independent advice from an orthopaedic surgeon (a surgeon who specialises in the musculoskeltal system). We found that the board did not evidence that a full history and examination of Mrs C was carried out at her out-patient appointment, and that the discharge letter to Mrs C’s GP did not detail any treatment plan. We considered this to be unreasonable. We also found that, following Mrs C’s assessment and examination, her case was not discussed with a consultant prior to any decisions being made about her care and treatment. There was delay in Mrs C receiving treatment at the pain clinic which was partly due to a delay in the board dictating the referral letter. We found that this delay was unreasonable and exceeded the national waiting time standards. We upheld Mrs C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to take an adequate history and examination and for the delay in treatment.

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

• Orthopaedic Registrars should be reminded about the importance of good record-keeping, which should include a detailed history and examination and the treatment plan.
• Decisions about patient care within the Orthopaedic Spinal service should be made with appropriate senior supervision and this should be recorded.
• Orthopaedic Registrars should adhere to reasonable timescales when dictating medical correspondence.
• Patients with chronic back pain should be treated within national wait time standards. The board should consider advising patients in a timely manner that they may not be seen within waiting time targets.

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.