Decision Report 202000038

Summary

C attended the A&E department at the Royal Infirmary of Edinburgh having suffered a fall and was diagnosed with muscular pain. They re-attended four months later, when a diagnosis of fractured vertebrae was made. C complained to the board that there were failures to fully investigate their symptoms and arrange appropriate x-ray imaging at the initial attendance.

When responding to the complaint, the board had initially concluded that a ‘red-flag’ symptom had been missed which should have prompted imaging. They upheld C’s complaint, apologised and outlined the steps that they would take to learn from this. They subsequently reviewed their position with neurosurgery colleagues and decided that C had been managed appropriately.

We took advice independent advice from an emergency medicine consultant. We found that C was appropriately assessed and did not meet the criteria in the relevant guidelines for their injury to have been considered high-risk and requiring imaging. We did not uphold the complaint. We found that we weren’t critical of the board for reviewing and revising their decision. However, we were critical that they had not communicated this to C and shared recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform them that they had changed their position, as outlined in their final complaint response. 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:

• The board should follow-up on the findings of complaint investigations and ensure that any identified learning actions are taken forward. If the board decide against taking promised actions, and particularly if this is as a result of a change / retraction.

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.