Decision Report 201405426

Summary

Mr C complained that after breaking a bone in his foot, despite four visits to hospital over a six month period, staff at the Southern General Hospital failed to diagnose and treat him properly. As a consequence, he said that he suffered prolonged and unnecessary pain. Mr C subsequently had an operation abroad to remedy his foot problem. He then complained to the board. The board said that, generally, with the exception of his final attendance at hospital, he had been treated appropriately. However, they apologised that his final visit had been below the standard expected. They said that they had since learned from the situation.

The complaint was investigated and we took independent advice from a consultant in emergency medicine. We found that when Mr C first went to hospital after injuring his foot, he had been diagnosed with a low risk, undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) and treated accordingly. Although it was more rare, we found that he had actually suffered a high-risk, complex fracture (a Jones fracture) which required significantly different management as the blood supply to his foot could have been affected. His further attendances at hospital also failed to establish the nature of Mr C's fracture, so we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology recognising the failures in care and treatment identified; and
• ensure that appropriate staff in the A&E department are made aware of the circumstances of this case and the failures identified, particularly with reference to a Jones fracture.