Overview
On 2 July 2010 an Independent Advice and Support Worker from the Citizens Advice Bureau (Ms C), complained to the Scottish Public Services Ombudsman about Highland NHS Board (the Board) on behalf of her client (Mr A). The complaint was that there had been a failure to identify why Mr A was not healing from a fracture of his left tibia and fibula, sustained whilst playing football in May 2008. Ms C complained that the pain Mr A suffered following his fracture was not assessed properly. She also complained that the clinicians involved in his care did not consider the possibility of any other underlying conditions that may have been present. Mr A was ultimately diagnosed as suffering from osteosarcoma of the left knee.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board did not appropriately investigate Mr A's failure to heal from his left tibia and fibula fracture (not upheld);
- (b) Mr A's ongoing pain was not assessed properly (upheld); and
- (c) the Board failed to consider the possibility of the presence of underlying conditions (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) review the procedures within orthopaedic related departments to ensure they have robust systems in place to identify red flag symptoms;
- (ii) draw the findings of this report to the attention of all clinical staff involved in Mr A's care and treatment throughout the period of 10 May 2008 to 12 May 2009, so that they can learn from it; and
- (iii) provide Mr A with a full apology for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly