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Case ref:201906335
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Date:December 2020
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Body:Greater Glasgow and Clyde NHS Board - Acute Services Division
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Sector:Health
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Outcome:Upheld, no recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained to us that staff from Greater Glasgow and Clyde NHS board had delayed in identifying that they had compartment syndrome (a painful and potentially serious condition caused by bleeding or swelling within an enclosed bundle of muscles – known as a muscle compartment). C was admitted to Glasgow Royal Infirmary after a fall in their garden where they sustained a tibial plateau fracture (a break in the upper part of the shin bone). They had surgery for this and the board stated that there was no evidence of compartment syndrome at that time. C continued to suffer problems including wound leak, foot drop and numbness in their leg. They were taken back to theatre and it was identified that they had developed compartment syndrome of the muscles of the anterior (front) compartment of their lower right leg. This has had a significant impact on C’s life.
We took independent advice from a trauma and orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, given C’s high risk injury, the symptoms of excess pain and numbness and the signs of reduced sensation and weakness, it was unreasonable for the board not to have either measured the compartment pressure or performed fasciotomies (the skin and fascial compartment are cut open so that the compartment pressure is relieved). This should have occurred after C’s operation and it was unreasonable for C to have been discharged home without this being carried out. If compartment syndrome had been recognised early, and swift decompression performed, on balance, the extent of the surgery performed subsequently would not have had to be so severe and the functional outcome not as bad. Therefore, we upheld this complaint.
However, consultants from the board had already met C to apologise that the onset of compartment syndrome was not identified earlier. The board had also outlined further action they had taken to prevent this issue recurring. In view of this, we did not make any recommendations to the board.