Decision Report 201809064

Summary

Mr C complained about the care and treatment he received at Ninewells Hospital after he ruptured his Achilles tendon. After he was reviewed by a consultant, conservative (non-operative) treatment of his injury was initiated. After a number of reviews, Mr C was discharged. He requested a further review as he was concerned about the progress of his recovery but no further action was taken following this review.

Months after his initial injury, Mr C re-ruptured his Achilles tendon. He was reviewed the following day and it was decided that surgery was necessary. There was a delay in surgery taking place, partly due to the surgeon being on annual leave. When Mr C attended the hospital to receive surgery, he remained on the ward all day before being told in the evening that surgery would not be required. He then underwent surgery two days later.

Mr C complained to us about the care and treatment he received for his initial injury, including the fact that he did not receive physiotherapy after his cast was removed. He also complained about what he considered to be unreasonable delays and communication after he re-ruptured his Achilles tendon.

We took independent advice from an adviser with a background as a trauma and orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board had failed to provide reasonable or appropriate care and treatment to Mr C following his initial injury. Although conservative treatment was appropriate for this kind of injury, we did not consider that other treatment options were fully discussed with Mr C. In addition to this, we concluded that it was unreasonable for an appropriate form of physiotherapy not to be suggested or discussed with Mr C. We highlighted that there was no evidence to suggest that this contributed to Mr C re-rupturing his Achilles tendon. However, we concluded that there were failings in Mr C's care and treatment that had had a negative impact on his patient journey. Therefore, we upheld this aspect of the complaint.

In respect of the complaint about delays and communication, we found that the timescale for Mr C receiving surgery was reasonable. However, we considered that the internal communication and communication with Mr C on the day he was initially due to receive surgery was unreasonable. The records show that he remained on the ward, while fasting, from early in the morning until the evening. However, at some point during the day, his surgery was cancelled due to there being more urgent emergency cases. This information was not relayed to staff on the ward, despite them making enquiries. We did not consider the fact that the surgery was cancelled to be unreasonable, as it is understandable that emergency cases may have to take priority at short notice. However, when it was known that the surgery was cancelled, this should have been relayed to the ward as soon as possible. The fact that this did not happen resulted in further frustration and anxiety for Mr C. As a result of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably failing to fully discuss treatment options with him, discharging him without discussing physiotherapy or a home exercise programme and for keeping him in hospital despite the fact that the surgery had been cancelled earlier that day. The apology should meet the standards setout in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Where appropriate, a range of treatment options should be openly discussed with the patient and a shared decision-making approach taken.
• The board should reflect on what happened and ensure that appropriate follow-up actions are considered when a patient is discharged following an Achilles tendon rupture. This includes discussing relevant physiotherapy and home exercise options with the patient.
• Reflect on how this situation happened and consider whether there are any improvements that can be put in place to help prevent a similar situation from occurring again.

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.