Decision Report 201507657

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Ms A that Borders General Hospital failed to identify that Ms A had fractured a bone in her foot after she attended A&E on two separate occasions and failed to provide adequate treatment. Ms A's pain persisted for months and her GP referred her to an orthopaedic specialist. A scan identified the fracture.

In responding to the complaint, the board said that the initial x-rays were reported appropriately. However, in a late stage of our investigation the board reviewed the x-ray images and acknowledged there were failings in the fracture being identified by radiology and that the A&E department failed to review the radiology reports, which had shown abnormalities.

We took independent medical advice. We found that there had been failings by the A&E locum doctors who had reviewed Ms A. Specifically, their record-keeping and assessments were below a reasonable standard given the background to Ms A's injury and inability to bear weight. We were critical that the A&E department had not reviewed the radiology reports, which were abnormal. Furthermore, we found that both x-rays did show the fracture. We also considered that it was unreasonable that on each occasion she attended A&E, Ms A was not provided with crutches or given a follow-up appointment to check that her symptoms were resolving, given her inability to bear weight. We therefore upheld Ms C's complaint.

Recommendations

We recommended that the board:

• contact the first locum doctor in order that they may reflect on their practice at their annual appraisal for personal learning and practice improvement;
• provide evidence of the action taken in relation to the second locum doctor and the radiologist, discussing this case at their annual appraisals and ensuring the findings of this investigation are shared with them, including their assessments and record-keeping;
• provide evidence of the review they carried out into the patient management system and process for reviewing imaging reports requested by the A&E team to ensure it is effective and in line with national guidelines;
• apologise to Ms A for the failings identified; and
• consider issuing guidance for the A&E team regarding the necessity for follow-up of patients who are unable to weight bear following an injury.