Decision Report 202107843

Summary

C presented at A&E with a painful left foot. The diagnosis recorded in the medical records was a foot sprain. A few months later, C was diagnosed with a rare degenerative condition and a possible healing fracture in their foot was also noted.

C complained that the doctor at A&E had not physically examined the foot, had not carried out an x-ray and had not taken a medical history. As such, a possible fracture may have been missed and a diagnosis of the degenerative condition was not considered. As a result, C felt that the correct treatment was not offered.

We took independent advice from an emergency medicine adviser. We found that the condition in question is rare and unlikely to be diagnosed in an A&E setting. It was also not clear whether the possible healing fracture had been present at the time. However, it would have been appropriate to carry out a physical examination, to take a medical history and to carry out an x-ray. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a physical examination and not taking a medical history, such that an x-ray was not considered. 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:

• Clinicians should be reminded of the importance of carrying out a thorough physical examination and recording the patient’s medical history.

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.