Decision Report 201809165

Summary

Mr C sustained a serious pelvic injury with internal bleeding following a road traffic accident and was admitted to Ninewells Hospital where he underwent surgery to repair the internal bleed and his fractured pelvis. Mr C suffered a further internal bleed and complained that there was a delay in identifying this bleed. Mr C also complained that the physiotherapy input he received following his surgery was unreasonable and may have caused his fracture to move; and that he was provided with inappropriate pain relief and his respiratory rate was not monitored properly.

The board considered that Mr C was monitored appropriately and that any delay in identifying the internal bleed was due to the fact that the CT scan was occupied by another patient. The board also considered that the physiotherapy input and pain relief provided were reasonable.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a physiotherapist and a general physician . We found that Mr C was appropriately reviewed and monitored and that there was no unreasonable delay in identifying the internal bleed. We also considered that the pain relief provided was appropriate and Mr C's respiratory rate remained stable. We did not uphold these complaints. However, with regards to the physiotherapy input, we found the standard of record-keeping to be poor and there was a failure to establish a treatment plan with agreed goals. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to obtain all relevant information about him prior to beginning treatment and failing to establish a treatment plan with agreed goals. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Physiotherapy records should meet the minimum documentation standards and the quality of records should be audited regularly.
• The physiotherapist should reflect on their handling of this case and discuss their learning from it in a supportive manner with their line manager.

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.