Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.
In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.
At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.
Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.
We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.
We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.
Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.
Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.
We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.
In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint.
Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C:
| Complaint number |
What we found |
What the organisation should do |
What we need to see |
|---|---|---|---|
| (a) and (b) |
The Board failed to provide Mr C with a reasonable standard of care and treatment The Board's own complaint investigation did not identify or address the failings in Mr C's medical care
|
Apologise to Mr C for the failings in care and treatment identified in the report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
|
A copy or record of the apology. By: 19 September 2020 |
We are asking the Board to improve the way they do things:
| Complaint number |
What we found |
What should change |
What we need to see |
|---|---|---|---|
| (a) |
The Board unreasonably failed to identify Mr C's navicular fracture
|
X-rays of patients attending hospital with a possible fracture should be appropriately reported. Patients re-attending should have their presenting symptoms fully assessed and investigated
|
Evidence that the case has been discussed at a radiology Learning from Discrepancies meeting. Evidence that the Board have reflected on the failings identified in Mr C's case and given consideration to any required changes to processes and guidance. Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions). By: 19 November 2020 |
We are asking the Board to improve their complaints handling:
| Complaint number |
What we found |
Outcome needed |
What we need to see |
|---|---|---|---|
| (b) |
The Board's own complaint investigation did not identify or address the failings in Mr C's medical care
|
The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement.
|
Evidence that the Board have reviewed why its own investigation into this complaint did not identify or acknowledge the failings highlighted here, what learning they identified, and what action has been taken as a result. My findings have been shared with relevant staff in a supportive way for reflection and learning. By: 19 November 2020
|
Feedback
Points to note
- While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
- When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
- Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.