The plaster that was applied to Mrs E’s foot after her surgery on 26 September 2016
14. Mrs E says that before her surgery, the Trust told her that she would have a full foot plaster covering her foot, like a slipper, and she would be weight-bearing with a specially fitted boot. Mrs E says that after she had surgery on her left foot on 26 September 2016, the wrong plaster was put on her foot, which meant that she was unable to have a boot fitted.
15. Mrs E says the plaster only covered half of her foot, from her toes to halfway up her foot, and this meant she was unable to have a boot fitted. Mrs E says the surgeon refused to change the plaster, as they stated it would disturb the operation site.
16. At the local resolution meeting with Mrs E on 7 February 2019, the Trust confirmed the orthopaedic surgeon who treated Mrs E had advised a shoe would be fitted. The Trust stated the plaster that was fitted was a non-weight bearing plaster, and it would have split and disintegrated if the physiotherapist had tried to put anything on to it, or if Mrs E would have tried to weight bear.
17. The Trust said the type of plaster that was used was well established, and it was a full foot plaster of Paris. The Trust confirmed the operation note said Mrs E required a darco shoe and the shoe could not be fitted because the plaster was too large. It was acknowledged this was a different type of plaster and there was a lack of communication between the doctor and the therapists at the time. In its response to us, the Trust said there was a lack of communication from the orthopaedic surgeon. The post-operative notes were written, the physiotherapist attempted to follow the instructions, but was unable to do so. This was passed back to the orthopaedic surgeon, and they declined to change the plaster. The physiotherapist then dealt with the situation to enable Mrs E to be mobilised independently while non-weight bearing.
18. The Trust explained there was a problem with the change in the plaster, that this was different from what Mrs E was expecting, and it was not ideal. The Trust accepted responsibility for what happened and acknowledged it was not acceptable to have reduced Mrs E’s mobility just because the plaster was not fitted appropriately. It apologised to her for this, as well as for refusing to change the plaster, and for the impact this caused.
19. The theatre notes, dated 26 September 2016, record that after her operation, Mrs E would be heel weight-bearing in a buratto or darco shoe. Mrs E’s discharge notes, dated 28 September 2016, also state she should have been heel weight-bearing in a buratto or darco shoe after her surgery. It is clear from her records that Mrs E should have been weight-bearing with a buratto or darco shoe after her operation.
20. Our orthopaedic adviser stated there is no specific guidance in relation to the most clinically appropriate plaster to fit after such an operation. They informed us it is clinically appropriate to fit a half-foot plaster in the first instance, due to the risk of swelling of the foot after surgery. NHS guidance advises it is appropriate for the patient to limit weight-bearing for the first two weeks after surgery.
21. However, the clinical advice we have received informs us that a change in plaster may have made it possible for the darco shoe to be fitted. Our orthopaedic adviser also stated that a bigger plaster would likely have resulted in Mrs E being able to weight-bear. Our orthopaedic adviser has also informed us that the consistency of the plaster was appropriate, in that it was a plaster of Paris and there were no issues with this.
22. GMC guidance on good medical practice states: ‘You must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including: their condition, its likely progression and the options for treatment, including associated risks and uncertainties, the progress of their care, and your role and responsibilities in the team who is responsible for each aspect of patient care, and how information is shared within teams and among those who will be providing their care’.
23. Our orthopaedic adviser stated it is possible to weight bear with a fore foot plaster and a surgical shoe. However, as the shoe could not be fitted, more should have been done to try and look at options to change the size of the plaster to try and enable Mrs E to weight bear on her heel. This could have avoided her being non-weight bearing and hopping on her other leg. Our orthopaedic adviser stated it was not appropriate for Mrs E to be told she would not be able to weight bear without other options being considered first, that might have enabled her to weight bear.
24. Based on the evidence we have looked at and the advice we have received, we have found it was not appropriate for Mrs E to have been left non-weight bearing for two and a half weeks after her surgery. The Trust did not make any attempts to enable Mrs E to weight-bear after her operation, which is not in line with the guidance we have referred to above. The Trust has acknowledged this should not have happened and it should have done more to try and get Mrs E weight-bearing. We have found this to be a failing. We will discuss the impact of this later in the report.
25. We understand this would have been distressing and frustrating for Mrs E, as she was led to believe she would be heel weight-bearing after her operation, but this did not happen.
The Trust’s decision for Mrs E to mobilise using a zimmer frame after her surgery
26. Mrs E complains that she had to use a zimmer frame, which caused her to hop on her right leg, for almost three weeks until her plaster could be changed.
27. At the local resolution meeting with Mrs E on 7 February 2019, the Trust acknowledged it was not ideal to resort to the zimmer frame and said it should have worked harder to assist Mrs E to become mobile.
28. We have carefully considered if it was appropriate for the physiotherapy team to have advised Mrs E to mobilise using the zimmer frame. It is important to outline that we are considering this decision separately, and we are looking at whether the physiotherapy team appropriately treated Mrs E, after the Trust had refused to consider any options to try and make it possible for Mrs E to weight-bear using her plaster and a buratto or darco shoe.
29. The Trust established that Mrs E would not be heel weight-bearing, after the consultant refused to change the size of the plaster or consider any options to try and help Mrs E to heel weight-bear. The physiotherapist tried to see if Mrs E could mobilise using crutches. Mrs E was unable to use the crutches and so she was therefore advised to use a zimmer frame to help her mobilise.
30. We considered if the physiotherapist should have considered different options to the zimmer frame once it was established that Mrs E would not be heel weight-bearing. Our physio adviser has told us there were limited options available to the physiotherapist once it was established Mrs E would not be heel weight-bearing. Our physio adviser informed us it was appropriate to consider the use of elbow crutches first, however, Mrs E was unable to use the elbow crutches, and therefore the option of a zimmer frame was the only feasible option.
31. Section 4.2 of the HCPC guidance says that practitioners should be able to make reasoned decisions to initiate, continue, modify, or cease techniques or procedures, and record the decisions and reasoning appropriately.
32. Section 8.4 of the Quality Assurance Standards says that analysis should be undertaken following information gathering and assessment to formulate a treatment plan, based on the best available evidence.
33. Based on the evidence we have seen and the advice we have received, we consider the Trust’s actions were in line with this guidance, as weight-bearing was not an option for the physiotherapist. Mrs E was trialled on crutches first, but she was unable to use them and therefore the use of a zimmer frame was advised as the only alternative.
34. Based on the clinical advice we have received and the evidence we have considered, we have not identified a failing with the Trust’s actions.
Our findings on impact
The plaster that was applied to Mrs E’s foot after her surgery on 26 September 2016
35. Mrs E says that due to the hopping she had to do, this caused damage to her right leg, specifically her knee, thigh, hip, and ankle. Mrs E says her leg has changed colour and her knee is still swollen. Mrs E also says she has damaged a nerve in her back, and her leg quite often gives way.
36. Mrs E says she has been told she will never walk properly again, and that she is unable to walk without being in a great deal of pain. Mrs E says she is unable to engage in activities that she used to be able to do, such as table tennis and swimming, and as such it has impacted on her quality of life. Mrs E also says she has been unable to work since she had the operation.
37. At the local resolution meeting, the Trust stated Mrs E already had wear and tear in her hip and her spine. The Trust explained that individuals can function very well with wear and tear until reaching a threshold, and after that they will notice pain developing. The Trust stated it could not say that Mrs E’s hopping would have aggravated her condition, as everything can aggravate it, and the zimmer frame should have kept her well balanced. It said it is a handy aid for mobilising, as it reduces the weight going through the leg to improve the centre of gravity, and it is the best way to non-weight bear as it reduces strain in the upper extremities. The Trust said the hopping would not have caused arthritis, although it acknowledged it would not have helped.
38. Our orthopaedic adviser informed us there is no direct link between Mrs E having hopped for two and a half weeks, with the use of a zimmer frame, and the impact she is claiming. This is because the hopping is unlikely to have been the direct cause of the injuries she says she suffered. Our orthopaedic adviser told us that we cannot say Mrs E would not have suffered the severity of symptoms she did, had she been mobilising with a darco or buratto boot after her surgery. We are unable to say on the balance of probabilities that the impact Mrs E is claiming is linked to the failing we have identified.
39. After carefully considering all the evidence, and based on the clinical advice we have received, we are unable to link the injustice Mrs E is claiming to her having hopped for two and a half weeks, while mobilising using the zimmer frame.
40. However, our orthopaedic adviser told us that because Mrs E has arthritis in her leg, hopping for two and a half weeks could have made the symptoms worse.
41. We have found that hopping for two and a half weeks would have caused Mrs E additional pain and exacerbated the symptoms of her arthritis during this time. This would have caused Mrs E concern, inconvenience, and distress when it was established that she would not be able to heel weight-bear post-operatively.
42. Although the Trust has acknowledged it should have done more to try and enable Mrs E to be weight-bearing, and it has apologised to Mrs E at the local resolution meeting for this, we don’t consider this is enough to remedy the injustice that was caused. This is because our Principles for Remedy say that public bodies should try to offer a remedy that returns the complainant to the position they would have been in had the failings not occurred. If that is not possible, the remedy should compensate them appropriately. We do not consider that the acknowledgement and apology provided by the Trust goes far enough to address the impact we have described above. We will address this further in the recommendations section below.