Issue 1- The A&E registrar did not share with Mrs L the information that he believed he found evidence of an ‘old’ fracture
18. Mrs L complains that when she attended A&E, the registrar had seen a fracture on the X-ray but did not tell her as he believed it to be old. She says if she had known about this, she could have challenged it as she knew she did not have an ‘old’ fracture. She believes the registrar may have then changed his diagnosis and her treatment could have been different.
19. We considered what should have happened, in accordance with guidelines when the A&E registrar found what he believed was evidence of an ‘old’ fracture. National guidance from the GMC (Good Medical Practice, paragraph 49) states: ‘You must work in partnership with patients, sharing with them the information they will need to make decisions about their care’.
20. The Trust say that the A&E registrar noticed a fracture to the thoracic spine, however he felt this was not new. Therefore, he diagnosed Mrs L with a muscle injury, advised her to take co-codamol, to mobilise and he discharged her. The Trust has acknowledged that the registrar should have shared the information of the ‘old’ fracture with Mrs L. It has apologised and said the registrar has reflected on her case for learning.
21. We appreciate Mrs L later had an operation on her back and has concerns the registrar’s decision in A&E influenced the need for surgery. To inform our investigation of her concerns, we sought independent clinical advice.
22. Our spinal surgeon adviser explained in detail what happens when a vertebra fractures. The vertebra crushes down (usually more at the front than the back) and this is sometimes referred to as a ‘wedge compression fracture’. When viewed from the side, the normally square shaped vertebra becomes wedge shaped. In comparison, long bones can ‘snap’ and result in a gap between the bones until healing takes place.
23. As a result, fractured spinal vertebrae appear different on X-rays from long bone fractures with recent fractures not showing the usual gap in the bone. As there is no gap between the bones, the wedge-shaped fractured vertebra does not return to a normal square shape following healing.
24. Our spinal surgeon adviser said because of this, there is no way of determining the age of a spinal fracture on an X-ray. If this is required, it is usually assessed with an MRI looking for evidence of inflammation. They said this knowledge is likely to be beyond what might be expected of a doctor working in A&E. Our spinal surgeon adviser said the changes on the X-ray taken in A&E are subtle and might easily be missed. This explains some of the registrar’s decision making.
25. As the Trust has already acknowledged, the A&E registrar believed he had identified an old fracture in Mrs L’s vertebrae. The information above does not change the fact that the registrar should have communicated the findings of Mrs L’s X-ray to her in line with the GMC guidance we have referred to in paragraph 17 and did not do this. This is evidence of a failing.
26. We considered whether the failing had any impact on Mrs L. To help us decide if Mrs L’s treatment could have changed if she had the opportunity to challenge the registrars’ finding on the X-ray, we referred to our A&E adviser. They said that vertebral compression fractures are extremely common in postmenopausal women and this is the group Mrs L falls into. Approximately 25% of all postmenopausal women in the USA get a compression fracture during their lifetime. This is evidenced in the referenced article Permanente Journal 2012. The clinical paper ‘Diagnosis and Management of Vertebral Compression Fractures’ says more than a third of patients with vertebral compression fractures have no symptoms and are diagnosed by chance.
27. It is therefore common for clinicians in A&E to identify an existing and previously unnoticed vertebral compression fracture on X-rays, particularly in female patients of this age group.
28. We have seen advice to explain why the registrar made the decisions he did. However, Mrs L was denied the opportunity to discuss the findings of the X-ray and its implications for her treatment. She was excluded from the decision process. We find this to be a failing.
29. In order to decide if there is a linked injustice, we considered what our clinical advisers told us. Our spinal surgeon adviser said, even if the A&E registrar had identified the presence of an acute fracture, the standard initial treatment for this injury is conservative. That is, to discharge home with advice to rest, gentle mobilisation and pain relief. This means there is no significant difference between the advice given for muscle injury and that for an acute fracture. Therefore, we find that even if Mrs L had the opportunity to challenge the diagnosis, the advice given would have been the same. The Trust has addressed the lack of communication with an apology and learning. As we have found failings but no directly linked impact, we partly uphold this issue of the complaint.
Issue 2- Mrs L was misdiagnosed and was subsequently given incorrect advice to mobilise
30. Mrs L says that because the A&E registrar believed she had a muscle injury he told her to mobilise as much as possible. She complains this was the wrong advice. She says 80% of the vertebra disintegrated because she was not immobilised and as a result, she had to have a four hour operation. She believes this may not have been necessary if the A&E registrar diagnosed her properly and so given her different advice.
31. We understand that Mrs L has concerns about her treatment considering she found out later a fracture was present. To address this issue, we consulted with our clinical advisers. Our orthopaedic adviser said clinical records show Mrs L had a significant mechanism of injury, low back pain and tenderness. He said Mrs L should have been assessed for thoracic or lumbosacral spine injury as per the NICE guidelines for spinal injury.
32. The NICE guidelines for spinal injury outline what should happen for suspected thoracic or lumbosacral column injury. They say: ‘Perform an X-ray as the first-line investigation for people with suspected spinal column injury without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions (T1–L3). Perform CT if the X-ray is abnormal or there are clinical signs or symptoms of a spinal column injury. If a new spinal column fracture is confirmed, image the rest of the spinal column’.
33. The A&E registrar assessed Mrs L and arranged for an X-ray. This was clinically appropriate and in line with the NICE guidance quoted. Our orthopaedic surgeon adviser said the findings of the X-ray were not considered to be acute (new), despite back pain.
34. We referred to our spinal surgeon adviser. After reviewing the medical records, they said there are no indications Mrs L had any abnormal neurology (this is damage to the nerves as a result of the fracture) at any stage and that Mrs L was assessed and treated within the framework set out in the NICE guidance for spinal injury and for low back pain and sciatica.
35. We acknowledge the A&E registrar said he did not take further action because he considered the injury to be old. Our spinal surgeon adviser says there would have been limits to the knowledge of an A&E registrar regarding such injuries. Also, that it would not be obvious following the initial assessment and X-ray whether this fracture represented an unstable injury that might require surgical treatment. We see it is common for clinicians in A&E to identify longstanding and unrecognised vertebral compression fracture on X-rays.
36. It is, however, important to recognise that the doctor was assessing Mrs L in the context of a recent fall downstairs. In this situation, our A&E adviser said the correct, and safest, way to manage Mrs L would have been to assume that the fracture was new. The X-ray showed what the A&E registrar believed to be an old fracture. He diagnosed Mrs L with a muscle injury, and as would be usual practice for an injury of this type, did not request a follow-up for Mrs L or seek guidance from a spinal specialist. The A&E registrar made an incorrect diagnosis. This was a failing in care.
37. The misdiagnosis meant the Trust did not refer Mrs L for further investigations. We considered if there was any clinical impact of this. The X-ray report documented in the A&E notes states that there was ‘mild loss of vertebral height’ and no ‘evidence of retropulsion’ (collapse of the vertebral body backwards potentially putting pressure on the spinal cord).
38. Our spinal surgeon adviser said, even if the A&E registrar had identified the presence of an acute fracture, the standard initial treatment for this injury is conservative. That is, to discharge home with advice to rest, gentle mobilisation and pain relief. We have not seen that there is any significant difference between the advice given for muscle injury and that for an acute fracture. Therefore, even if she had been referred for further investigation, the treatment plan would not have been significantly different. The advice given on the day was reasonable and in line with guidance.
39. To provide a fully robust explanation to Mrs L, we also considered, if Mrs L had immobilised from 20 October 2018 when she presented at the Trust, could she have avoided surgery or could the injury have been less serious.
40. Evidence shows Mrs L had a wedge compression fracture. Our spinal surgeon adviser said there is no way of immobilising a fracture of this type. Resting in bed is usually only advised until the patient can stand and walk, which Mrs L was able to do.
41. Our adviser said there is a spectrum of opinion about the treatment of spinal fractures and the most effective treatment pathways have yet to be established. Opinions differ as to whether spinal fractures of this type are best treated conservatively or with surgery. Most osteoporosis related wedge compression fractures resulting from falls are treated without surgery.
42. The decision to operate is based on expert opinion, patient choice and an assessment of the ‘stability’ of the fracture. It would not be obvious following initial assessment at A&E whether this fracture represented an unstable injury that might require future surgical treatment. Given this, we consider it is reasonable to initiate a trial of conservative treatment in the first instance, as occurred in this case.
43. As we have found failings but no directly linked impact, we partly uphold this issue of the complaint.
Issue 3- Mrs L was not given adequate pain relief for her condition
44. Mrs L complains she suffered nine days of unnecessary, excruciating pain at home because the pain relief provided was inadequate for the level of injury she had. As a result, she subsequently attended Cardiff Hospital on 29 October 2018 where staff administered her with pain relief medication shorttec and longtec (both opioids) which relieved her pain.
45. Clinical records show that when Mrs L presented at Cardiff Hospital, getting her pain under control was a key reason for her admittance. It took over a week of trials for staff to find the right level of pain management.
46. The medical records from the Trust do not detail what pain relief was given to Mrs L on admission. Documentation shows that medication was administered at 8.20am but what this was, is not recorded. It is also noted that she had been given pain relief by the paramedics prior to attending A&E. However, the administration of this pain relief is not documented.
47. The Trust response dated 8 May 2019 explains staff administered codeine to Mrs L upon triage at A&E and she was prescribed co-codamol on discharge.
48. Our A&E adviser noted that Mrs L had pain scores recorded at 7.36am (pain 10/10), 8.18am (9/10) and 8.49am (5/10). This indicates the medication she was given had a positive effect on her pain.
49. BNF guidance regarding chronic pain says that opioids should be prescribed in carefully selected individuals when other therapies have been insufficient and when the benefits outweigh the risks. As Mrs L’s pain scores had reduced during her admittance, we consider the pain relief prescribed was appropriate for that stage of her condition.
50. We are very sorry that Mrs L was in so much pain and we were glad to hear that Cardiff Hospital resolved the issue for her. Mrs L told us we had limited information about her pain relief and that she was also given some morphine in A&E and she believes this explains the lowering of the pain score. Our view is that it was not appropriate to prescribe a higher level of pain relief at A&E, based on her condition and diagnosis at the time. We are therefore satisfied she was appropriately assessed and treated for her pain. We do not find there are any failings in relation to pain relief.
51. To summarise, our report finds that there was no failure by the Trust regarding the pain relief it provided. We do see failings by the Trust regarding the sharing of information and the diagnosis of the fracture when Mrs L attended A&E. In terms of the distress this caused, we are satisfied the Trust has appropriately addressed this. We do not consider the indicated failings can be directly linked to a significant clinical injustice. We partly uphold this complaint.