ED attendance on 30 October 2017
23. Mr T complains that when he attended the ED, the nurse did not listen to his concerns about his foot. He has had considerable medical treatment in the past and says he is an expert patient. He knows when something feels wrong with his body and believes the nurse should have referred him for further investigation of his injury. We understand that Mr T was very concerned about his foot when he attended the ED, and we are sorry he feels his concerns were not taken seriously.
24. The Trust said an emergency nurse practitioner examined Mr T’s neck and foot when he attended the ED. The records show Mr T communicated that the bone in his foot may not be in the right place. The nurse noted a scabbed area on the sole of his foot near his right toe, the site of previous surgery, but did not see any bruising or swelling. The nurse did not consider there were signs of new injury or of deformity to the bones in his foot, so did not request an X-ray or any further investigations.
25. In support of his complaint, Mr T submitted a statement from a personal assistant supervisor who accompanied him to the ED. The personal assistant said that following the accident, Mr T was suffering from a sore neck, back, and a swollen foot. His foot had a red wound on the sole which did not blanch when touched (the skin did not go pale when pressed). He said Mr T showed the nurse practitioner the area of pressure and swelling and expressed his concern he had a broken foot.
26. The personal assistant also explained that on 2 November, a hole opened on the bottom of Mr T’s foot and his care team dressed this with a pressure relieving dressing. Mr T has confirmed that he has a care team who attend to his personal needs each day.
27. Guidance from the NMC’s The Code says nurses must:
‘assess need and deliver or advise on treatment, or give help (including preventative or rehabilitative care) without too much delay and to the best of [their] abilities, on the basis of the best evidence available and best practice.’
It also says nurses must communicate effectively and ‘act in partnership with those receiving care’.
28. Our emergency medicine adviser has explained that a clinician would look for bruising and swelling as indication of a dislocated joint. In this case, the nurse practitioner examined Mr T’s foot but did not see bruising or swelling to indicate a more serious injury.
29. We acknowledge Mr T’s personal assistant said that the foot was swollen which does not reflect the account documented by the nurse. We do not discount this evidence and appreciate that Mr T was very concerned about his foot. There is no further independent evidence available for us to consider what the condition of Mr T’s foot was at the time of his attendance. It is therefore not possible for us to reach a robust view of whether his foot was swollen or not.
30. Our emergency medicine adviser has further explained that even if Mr T’s foot was swollen, this does not mean that the nurse should have requested further investigations or an X-ray. The description of Mr T’s skin not blanching when touched also does not indicate there was a new injury and does not suggest that further action was needed at that time.
31. Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) say there must be a clinical justification for a person to undergo exposure to radiation. An X-ray exposes a person to radiation and a practitioner must be able to say that the benefit of the exposure will outweigh the risk of it. In this case, the nurse did not consider there was indication of injury that required further investigation, and so there was no justification for requesting an X-ray.
32. We are sorry Mr T did not feel that the nurse practitioner listened to him, and we understand this must have been a distressing experience. In-line with the NMC guidance quoted in paragraph 27, we would expect a nurse to listen to a patient and communicate effectively. The nurse documented that Mr T felt a bone in his foot was out of place and too this into account when examining his foot. We are satisfied the records support that the nurse took his concerns into account.
33. Following careful review of the evidence, we consider the nurse practitioner assessed Mr T and reached an appropriate clinical decision based on this examination. We do not consider there is evidence to support that Mr T should have had an X-ray on this date. With no indication of a new injury, we would not expect follow-up care to be arranged. We are satisfied the clinical assessment and standard of care provided meets the NMC standards set out in paragraph 27.
ED attendance on 5 February 2018
34. When Mr T reattended the ED on 5 February, he complained he had an open wound through which he could touch bone, but ED clinicians did not take appropriate action to provide care. Mr T had to ask his GP to refer him back to the orthopaedic team and said this considerably delayed him receiving treatment. He also complained he was not told he had a dislocated toe.
35. The statement from Mr T’s personal assistant says that the wound on Mr T’s foot opened on 2 November 2017. His care team dressed this with specialist dressings used for managing ulcerative wounds. When the wound did not heal, Mr T returned to the ED.
36. The Trust said a nurse practitioner examined Mr T and saw there was a cavity on his foot. This was clean and dry, and his foot was warm and pink. There was no evidence of infection or deformity. An X-ray was taken, and a consultant reviewed this alongside a previous MRI. The consultant considered there was a dislocation, and this was the same injury Mr T had treatment for in 2016. There was no evidence of a new injury or fracture.
37. Our emergency medicine adviser and orthopaedic adviser have both reviewed the X-ray taken on 5 February 2018. They have confirmed this does not show evidence of a dislocation to any of Mr T’s toes. Our emergency medicine adviser has explained that after surgery, Mr T’s fifth toe has formed what looks like a false joint, known as pseudo-arthrosis. The remaining joint and the end of a bone make up this false joint. It is possible that on initial reading of the X-ray, the ED clinician misinterpreted the image of this false joint as a dislocated toe.
38. The X-ray report from the Trust’s radiologist confirms this shows evidence of the previous surgery Mr T had to the fifth toe on his left foot. It showed no bony injury and no evidence of infection. The report does not say any of his toes were dislocated.
39. An MRI later taken in September 2018 showed the dislocation of Mr T’s fourth toe. We understand Mr T was concerned that the ED clinicians did not tell him about this in February 2018. The Trust’s complaint response likely added to this concern because it apologised that he was not told about the dislocation and commented it was difficult to say if the car accident had caused this.
40. The X-ray taken on 5 February 2018 does not show Mr T’s fourth toe was dislocated and so we cannot say this injury was caused by the car accident on 30 October. Our orthopaedic adviser has explained that paraplegia can cause muscles to go into spasm which can cause joints to dislocate. This was the likely cause for the toe’s later dislocation.
41. Despite the ED clinicians potentially reading the X-ray, this had no impact on Mr T. This is because they did not tell him about the dislocation and considered this was an old injury that did not require urgent follow-up care. Mr T was told to contact the orthopaedic surgeon’s secretary for an appointment for follow-up care for the non-healing wound on his foot.
42. The records show the nurse practitioner cleaned Mr T’s wound, gave him some spare dressings, and advised him to return to the ED if his condition deteriorated, or if he had any concerns. They took a swab to check for infection. The records say Mr T was happy with this plan and had no questions.
43. In his complaint to us, Mr T has said he feels the ED should not have just sent him home when he had a dislocation and an open wound. He said that he is prone to suffering with infection and has questioned how this was acceptable care. He said he did not feel he was listened to.
44. We understand Mr T did not feel that he was listened to when he attended the ED, and we are sorry for the distress this has caused him. When reviewing the ED records from 5 February, we can see that the nurse practitioner documented that Mr T thought he may have a break in his toe because of how it felt to touch, and it felt ‘wrong’. This description reflects what Mr T has told us about his concerns at the time of this attendance. We consider the records support that the nurse practitioner listened to what he had to say and took this into account during their assessment. This standard of communication is in-line with NMC guidance quoted in paragraph 27.
45. In terms of the clinical decisions made, our emergency medicine adviser has explained that it is not uncommon for people with paraplegia to have dislocated joints. If the dislocation is not causing the person any issues, it can be better not to intervene. While we have not seen any evidence that Mr T had a dislocated toe on 5 February, we have considered the actions of the ED team, who thought that he did.
46. In this case, the ED team understood the orthopaedic team had treated Mr T for a similar condition two years ago. The nurse practitioner advised Mr T he should see the orthopaedic surgeon again for follow-up care.
47. Guidance from the NMC: ‘The Code’ says nurses must work co-operatively, and this includes respecting ‘the skills, expertise and contributions of [their] colleagues, referring matters to them when appropriate’. We consider the advice to contact the orthopaedic team was clinically appropriate and in-line with NMC guidance. This would enable the team to re-review Mr T’s condition and make the relevant decisions for his care.
48. We have considered whether the ED staff should have made a referral to the orthopaedic team on Mr T’s behalf. We acknowledge his concern that this did not happen. Our emergency medicine adviser has explained there was no evidence Mr T had a new acute injury that required urgent care. It was therefore reasonable for the nurse practitioner to advise him to contact the orthopaedic surgeon in follow-up to his ED attendance. As noted above, it is recorded that this plan was discussed with Mr T, and he was happy with this.
49. We appreciate that asking Mr T to take this action meant he had to arrange to see his GP who could then make this referral, and this did not happen until 19 March 2018. We are sorry that Mr T does not agree that this should have happened, and we are sorry for this distress this has caused him. Following careful consideration of his condition on this date and his clinical history however, we consider the plan made by the ED staff was clinically appropriate. We are satisfied that the care provided on this date meets the standards set out in the NMC guidance quoted in paragraph 27.
Orthopaedic care
50. Mr T complains he had to wait for long periods of time between each of his appointments with the orthopaedic surgeon and did not undergo surgery until a year after referral for treatment. He feels it was inappropriate to leave him for such a length of time with an open wound when he is very susceptible to developing infections. Mr T says he feels he was treated differently because he has paraplegia.
51. In response to our investigation, the Trust said the orthopaedic surgeon decided to first treat Mr T with orthotics to see if non-invasive care could help the wound on his foot heal. The surgeon considered the orthotics worked well to help heal the wound at first, but when the clinical picture changed, and in discussion with Mr T, he then agreed to operate. Mr T’s wound had healed on his discharge from the service.
52. The Trust considers the treatment pathway started when the orthopaedic surgeon first reviewed Mr T in May 2018, and the delay in going ahead with surgery was due to the decision to first try non-invasive treatment.
53. The NHS Constitution Handbook says NHS services are provided based on clinical need. It states patients have the right to ‘start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions’. Amongst the exceptions for not meeting this timescale are if a consultant considers delaying treatment is in in the patient’s best clinical interest.
54. The NHS website explains that waiting times end once treatment begins, or if a clinician decides not to treat. It also confirms that the right to an 18-week waiting time does not apply if, ‘it is clinically appropriate for your condition to be actively monitored in secondary care without clinical intervention or diagnostic procedures at that stage’.
55. The Department of Health: Referral to treatment consultant-led waiting times - Rules Suite confirms:
‘Ultimately, it is for the professionals in charge of the patient’s care to decide whether waiting longer than 18 weeks is in the patient’s best interests, and to communicate this to the patients concerned’.
56. The Trust’s Patient Access (Waiting List/ Waiting Times) Policy confirms it offers appointments according to clinical priority and this means that more urgent cases will be seen first. We are satisfied this approach is in-line with the NHS Constitution.
57. Mr T’s GP referred him to the orthopaedic team on 19 March 2018. This was a routine referral, and our orthopaedic adviser has confirmed this was appropriate because Mr T did not have an acute infection and there was no clinical urgency at that time. The first appointment with the orthopaedic surgeon took place on 3 May, just over six weeks from the date of referral.
58. At this first appointment, the surgeon documented Mr T had a 0.5cm ulcer under his fourth toe which had not healed despite attempts to dress this at home. The surgeon noted the bone of the joint of the fourth toe was putting pressure on the skin, stopping the wound healing. He decided to first refer Mr T to the orthotics team to see if orthotics could relieve the pressure on the foot to help the skin to heal.
59. We note that Mr T suffered from a similar condition in 2016 when his fifth toe dislocated, putting pressure on the skin and causing an ulcer that did not heal. The same pattern of treatment was tried then, to first see if orthotics could allow the wound to heal.
60. The GMC’s Good Medical Practice says doctors must, ‘provide a good standard of practice and care’. If they assess, diagnose, or treat patients, they must:
‘15. (…)
b. promptly provide or arrange suitable advice, investigations or treatment where necessary
c. refer a patient to another practitioner when this serves the patient’s needs.’
61. Our orthopaedic adviser has commented Mr T has a long-term condition and it was appropriate to first see if orthotics could help heal Mr T’s wound on his fourth toe without the need for surgery. A person with paraplegia is more at risk of developing infection and healing can be difficult. Surgery involves making a new wound and there is the risk that this may not heal well.
62. The medical paper: ‘Physiological changes in tissues denervated by spinal cord injury tissues and possible effects on wound healing’ explains that following a spinal cord injury, changes happen to the body that affect the wound healing process. The ability of the skin to heal is particularly affected in the tissue that is below the level of injury. This means wounds and ulcers can be difficult to treat and keep closed in patients with a spinal cord injury.
63. We acknowledge Mr T’s comments that he feels he has been treated differently because he has paraplegia, and we are sorry that he feels he has not received an appropriate level of care. Our orthopaedic adviser has confirmed the changes caused to the body by paraplegia means it is not possible to compare the care given to patient with this condition to a patient with full sensation in their limbs. They note that it is not unusual for a person with paraplegia to have problems with their feet and ulcerations can happen because of this condition.
64. Following referral to the orthotics team, the orthopaedic surgeon allowed time to see if the orthotics would help the wound heal. We appreciate that it took time to see if the orthotics would be successful, however, taking into account the views of our adviser that surgery itself can lead to further issues with wound healing, we consider it was appropriate to first wait to see the outcome of this treatment. Indeed, the records show that there was improvement in the wound over the months that followed and by December 2018, it had healed.
65. Although the orthopaedic surgeon did not start discussing the option of surgical treatment until September 2018, this does not mean that no action was being taken to manage Mr T’s foot. The decision not to proceed with invasive treatment from the first appointment was because the surgeon considered trying orthotic care first was in Mr T’s clinical best interests. We are satisfied this decision was clinically appropriate and this meets the standards set out in the GMC’s Good Medical Practice, as quoted paragraph 60. This also meets the exemption criteria for not meeting the 18-week pathway to treatment, as set out in the NHS Constitution.
66. While the surgeon wanted to treat Mr T’s wound with orthotics, the records show he also considered Mr T’s concerns and reviewed his foot at each appointment. In August, the surgeon documented he planned to speak with his colleagues about Mr T’s case, and in September he planned to discuss this at an MDT meeting for complex cases.
67. Our orthopaedic adviser has explained that Mr T’s case was complex and before the surgeon could make decisions for his care, he needed to carry out further investigations and discuss this with specialist teams. We appreciate that this added additional time to the progress of Mr T’s treatment.
68. We consider it was appropriate for the surgeon to carefully decide the treatment that would be suitable for Mr T should the orthotics not be successful. The action to discuss the case with colleagues meets the standards set out in the GMC’s Good Medical Practice which says doctors must, ‘consult colleagues where appropriate’.
69. Mr T has commented he was not given advice on how to care for his foot between appointments. His personal assistant described Mr T’s foot as being swollen throughout 2018, and the care team dressed the wound as a pressure sore. From the records, we can see the surgeon assessed Mr T’s foot at each appointment and noted the skin was pink, the tissue healthy and it showed no sign of infection.
70. The GMC’s guidance for Good Medical Practice says doctors, ‘must give patients the information they want or need to know in a way they can understand’. Our adviser has commented there is no specific advice we would expect the surgeon to have provided to help care for his wound between appointments.
71. Mr T had a care team who assisted him with dressing the wound on his foot, and we note Mr T had a wound very similar to this in 2016. There is no record to show he raised concern about how to care for his foot between appointments, and the surgeon had no concerns with the condition of the wound. We would expect to see a doctor give a patient the relevant information they may need, in-line with the GMC guidance quoted in the paragraph above. In this case however, the records do not support that Mr T needed or requested advice about wound care from the surgeon or the orthopaedic team. We are sorry if this was not the case, but if the team were unaware of any problems Mr T was having with managing the wound, we cannot be critical it did not offer advice.
72. When the orthopaedic surgeon reviewed the MRI in September 2018 and this showed possible osteomyelitis and the dislocation of the fourth toe, he re-considered the clinical course of treatment for Mr T. On 4 December, Mr T reported concern that his foot would swell, and it made him feel shivery. The surgeon noted that the wound had healed, but in consideration of Mr T’s comments and the concern of infection, agreed to go ahead and operate to clean and remove any infected or damaged tissue. Our adviser has confirmed the action to review Mr T and go on to plan surgery was clinically appropriate.
73. The Trust’s Patient Access (Waiting List/ Waiting Times) Policy says that when a decision is made that a patient requires inpatient surgery, or day surgery, a surgical pre-assessment should take place within 10 working days of this decision. At this appointment, a date for surgery should be agreed with the patient.
74. The surgeon agreed to go ahead with surgery on 4 December 2018 and in-line with the Trust’s Patient Access Policy quoted in the paragraph above, a pre-assessment should have taken place by 18 December. The records show a nurse carried out a pre-assessment with Mr T on 29 January 2019. This is a delay of six weeks. We consider this delay was a failing.
75. In response to our provisional views report, the Trust has agreed that in-line with its Patient Access Policy, there was a delay in arranging Mr T’s pre-assessment and it did not meet the 10-day target. It explained it arranges surgical pre-assessments within three months of the date intended for surgery. It would not schedule a pre-assessment until it could confirm a date for surgery to make sure this took place within the three-month period. The Trust has confirmed it will update its policy to reflect this approach.
76. Mr T says the delays in progressing his care caused his condition to deteriorate. He says prompter treatment could have prevented the infection he later went on to suffer with and would have stopped the progression of osteomyelitis. We have carefully considered if we can link a clinical impact to the delay in arranging a surgical pre-assessment.
77. The Trust has told us that the availability of surgical pre-assessments does not limit a patient being able to access timely surgery. The wait for surgery depends only on the surgeon’s waiting list. We cannot therefore link the delay in Mr T’s surgical pre-assessment to when surgery took place. We do consider however, that the delay in arranging the pre-assessment contributed to Mr T suffering distress as he waited for treatment to be arranged. We have made our recommendation at the end of this report to address this.
78. At the pre-assessment on 29 January 2019, a nurse agreed a date for surgery of 20 February 2019 with Mr T. The nurse noted that he had low blood pressure and was tachycardic (had a fast heart rate). Mr T said that this was normal for him. The nurse said this would need to be discussed with the anaesthetist. An anaesthetist planned to see Mr T on 14 February 2019 to assess him before surgery, but the records show Mr T did not attend the appointment. This resulted in the cancellation of surgery planned for 20 February.
79. The Association of Anaesthetists of Great Britain and Ireland guidance: ‘Pre-operative Assessment and Patient Preparation’ says an anaesthetic pre-assessment should take place before surgery goes ahead. This is to make sure the patient is fit and prepared for surgery, to assess risks and to formulate an anaesthetic plan. It says patients can have existing health issues that need careful assessment and adjustments made for their care in advance of surgery going ahead.
80. The Trust’s Patient Access (Waiting List/ Waiting Times) Policy confirms that an anaesthetist review should take place before an operation. The decision of the anaesthetist of whether the patient is fit to proceed leads to the decision to admit them for surgery as planned, or not. Due to Mr T not attending this assessment, the clinical team could not confirm if he was fit to go ahead with surgery on 20 February. We consider it was in-line with the Trust’s policy to cancel the surgery because important pre-surgery checks had not been completed.
81. Following this cancellation, the Trust offered Mr T a date for surgery of 20 March. On 20 March, he attended the hospital and underwent further pre-operative assessments. The surgeon reviewed Mr T and saw his fourth toe looked more infected. He ordered an urgent MRI, swabs of the wound and intravenous antibiotics. Mr T was added to the surgery list for 22 March and the surgeon planned to re-review him on that date.
82. The MRI taken in March did not show any deterioration of Mr T’s condition and showed the osteomyelitis had improved. The surgeon reviewed Mr T on 22 March and reviewed the MRI scan. While this did not show concern with the osteomyelitis, the surgeon thought there may be an underlying infection. The surgeon prescribed Mr T a course of antibiotics and decided he was not fit for surgery that day. He scheduled surgery for 27 March, and this proceeded without issue.
83. The Trust’s Patient Access (Waiting List/ Waiting Times) Policy says if medical reasons cause the cancellation of an operation, there should be arrangements for the patient to receive further treatment. Clinicians should then re-review the patient to decide if treatment should go ahead. If it is decided to go ahead with the operation, this should be arranged as soon as possible, and within 28 days of the cancellation. In Mr T’s case, the operation went ahead five days after cancellation on 22 March. We consider this was an appropriate timeframe because it allowed Mr T to complete a course of antibiotics to make sure he was fit for surgery.
84. We consider there is appropriate clinical justification for why a decision was not made to operate on Mr T’s toe until December 2018. The surgeon appropriately reviewed Mr T during this time and monitored his condition. When there was evidence of osteomyelitis, the surgeon discussed this with colleagues and agreed a new treatment plan with Mr T. We are sorry Mr T felt there were delays in treatment and understand this was a distressing experience for him. We consider there was six-week delay in arranging a surgical pre-assessment, but we have not seen concern in the remaining areas of care.