Chain reaction

Author: Dr Marika Davies, Casebook editor-in-chief

Miss P, a 35-year-old teacher, attended her local emergency department with wrist pain following a fall off her bicycle. She saw Dr A, who examined her and documented that there was some generalised bony tenderness. He arranged an X-ray, which was normal, so reassured the patient and sent her home with analgesia.

The X-ray was later reviewed by a radiologist, who reported it as normal, but recommended follow-up as a scaphoid fracture could not be ruled out. The report was sent to the patient’s GP.

Two weeks later Miss P attended her GP, Dr K, complaining of ongoing pain. The radiology report was not in the patient’s notes, and the GP relied on the history from the patient that the X-ray had been normal. The notes stated that there was a full range of movement, but there was no record of an examination. Dr K reassured the patient and changed her analgesia.

A few weeks later the patient was still in pain so returned to her GP, who arranged an X-ray. This showed non-union of a fracture of the scaphoid. The patient was referred to an orthopaedic hand surgeon and required bone grafting under anaesthesia.  

Miss P made a good recovery, but wrote to Dr K raising concerns about the delay in diagnosing the scaphoid fracture. Dr K took advice from Medical Protection, and was advised to handle the concerns as a complaint using the practice complaints procedure. She was also advised to carry out a significant event analysis, and to ask the patient for consent to forward her complaint to the hospital where she had first been seen.

On investigating the incident the practice found that the radiology report had been received but had been scanned into another patient’s records in error, and noted that the two patients had very similar names. A number of flaws in the process for receiving and acting on X-ray reports was noted, so changes were put in place, along with further staff training. Dr K acknowledged that she had not examined the patient or advised her to return if the pain did not resolve.

The hospital contacted the Emergency Department (ED) doctor and asked for his comments on the complaint. On reviewing the notes, the doctor saw he had not documented the mechanism of injury, whether there was any anatomical snuffbox tenderness, or what advice he had given the patient. As such, there was no evidence that a scaphoid fracture had been considered or the appropriate advice given. The doctor responded to the hospital saying that he had learned from the incident, had reflected upon it, and had discussed it with his clinical supervisor.

Medical Protection helped Dr K and her complaints manager to prepare a joint response from the practice and the hospital, which set out the findings of the investigation into the complaint. The letter provided a full explanation for the consultations she had attended, and acknowledged that there had been shortfalls in the care provided, for which they apologised. The practice and the hospital demonstrated that they had taken her concerns seriously and had taken steps to reduce the risk of similar incidents occurring again. They offered to meet with the patient to discuss any further concerns, and advised her of her right to refer her complaint to the Parliamentary and Health Service Ombudsman if she remained dissatisfied.

Miss P did not take her complaint further.

Learning points

• Maintain a high index of suspicion of scaphoid fractures when treating and reviewing wrist injuries. If symptoms suggest a broken scaphoid, the injury should be treat as one, even if it is not seen on X-ray.
• Document negative findings and advice given to patients - without adequate documentation it is difficult to reconstruct what took place during a consultation some time after the event, and to justify that the patient was managed appropriately.
• Ensure safety nets are in place, and that patients know what symptoms to be concerned about and when to return to see you.
• A full investigation and co-ordinated response are key to providing a complainant with a detailed and thorough explanation.
• Dealing with concerns promptly and swiftly can help to prevent them from escalating into a claim. In this case both the hospital and the practice provided a full explanation and apology, and showed that lessons had been learned.