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University Hospitals Birmingham NHS Foundation Trust

P-001183 · Report · Decision date: 10 November 2021 · View University Hospitals Birmingham NHS Foundation Trust scorecard
Treatment Transfer, discharge and aftercare Clinical negligence harms learning
Complaint (AI summary)
Mrs E complained that after foot surgery, the wrong plaster was applied, preventing a surgical boot and forcing her to use a walking frame, causing damage to her right leg.
Outcome (AI summary)
Partly upheld. Mrs E was left without a surgical shoe for two and a half weeks due to the plaster, impacting her mobility. The Trust's apology was insufficient.

Full decision details

The Complaint

5. 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. Mrs E says the wrong consistency of plaster was used, and it only covered the front half of her foot. Mrs E complains that this also meant she had to use a walking frame, which caused her to hop on her right leg for almost three weeks until her plaster could be changed.

6. Mrs E says that due to the hopping that she had to do, it has caused damage to her right leg, specifically her knee, thigh, hip, and ankle. Mrs E says her leg has changed colour, and that her knee is still swollen. Mrs E also says she has damaged a nerve in her back, and her leg quite often gives way. Mrs E says she has been told she will never walk properly again. Mrs E says that she is unable to walk without being in a great deal of pain and 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.

7. Mrs E seeks an apology, an acknowledgment of failings from the Trust, and a financial remedy.

Background

8. Mrs E was initially seen in clinic on 26 July 2016, with a history of bunion deformity of her left big toe, (a bunion is a bony deformity that causes the big toe to tilt, crowding the smaller toes) mid foot, and ankle pain. Her X-rays also showed osteoarthritis in her left big toe and in her left ankle. Mrs E had a history of osteoarthritis in her lower lumbar spine, her left hip, and right knee.

9. Mrs E had corrective surgery for the deformity of her left big toe on 26 September 2016. At the end of the procedure, she had a forefoot plaster applied to her foot and she was told to mobilise her heel by weight-bearing in a darco shoe. A darco shoe is worn after surgery to allow the patient to weight bear while keeping the dressing clean and reducing weight-bearing pressure on the forefoot.

10. The physiotherapist advised Mrs E to mobilise, without bearing weight, with a zimmer frame for two weeks, until she was seen in clinic. Following her foot operation, Mrs E was seen five times in clinic, on 12 October 2016, 26 October 2016, 7 November 2016, 13 December 2016 and 25 January 2017. During these appointments, she had a wound check, X-rays, and blood tests, which showed that the wound healed well, the deformity was corrected well, and she had no local complications.

Findings

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.

Our Decision

1. We have identified one failing, as Mrs E was left without a surgical shoe for two and a half weeks after her bunion surgery. This impacted her mobility during that time. Although the Trust has acknowledged it could have done more to try and change the plaster, and to help Mrs E to be fully weight-bearing, it has apologised for this. We do not consider this is enough to remedy the injustice that was caused to Mrs E. We have upheld this part of Mrs E’s complaint. We will explain our rationale for this in this report.

2. We have not identified a failing with the Trust’s decision to advise Mrs E to mobilise using a zimmer frame, once it was established there were no other options for her to be able to mobilise while she could not bear weight. We will explain our rationale for this in this report.

3. We are recommending that the Trust issues Mrs E with a written apology and an acknowledgement of what went wrong. We are also recommending the Trust issues an action plan to show how it has improved its level of service in the trauma and orthopaedic department, or how it will do. We are also recommending the Trust provides Mrs E with a financial remedy in recognition of the impact the Trust’s failing caused her, due to not being able to weight-bear after her operation.

4. We were very sorry to learn of the issues that Mrs E has raised. We understand she has been through a very difficult and distressing time since her operation in 2016.

Recommendations

43. In considering our recommendations, we have referred to our ‘Principles for Remedy’ (our principles). These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

44. We acknowledge the Trust has apologised to Mrs E in person at the local resolution meeting it had with her. However, we recommend the Trust should write to Mrs E to acknowledge the failing we have identified and apologise for the impact this has caused her. This letter should be sent to Mrs E and a copy should be provided to us within 30 days of us issuing this report.

45. Our principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Trust produces an action plan to show how it has improved, or will improve, the level of service it provides. Specifically, to patients in the trauma and orthopaedics department, in relation to post-operative care following bunion surgery, to ensure that the best outcome for the patient is achieved. The action plan should be sent to Mrs E and a copy should be provided to us within 30 days of us issuing this report.

46. Our principles also state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

47. To decide on a level of financial remedy, we have referred to our severity of injustice scale. Our scale allows us to ensure the recommendations we make are transparent and consistent for everyone who uses our service. After careful consideration, we consider the injustice we have identified fits with level 2 on the scale. The description for this in relation to physiological impact is, ‘Minor pain lasting from a few days to a month; severe pain lasting for no more than a week’.

48. Mrs E had to hop on one leg to mobilise for two and a half weeks. We have found this would have worsened the symptoms of her arthritis. While we cannot link the failing to the injustice Mrs E is claiming, Mrs E would have been caused additional pain and distress for the time she was hopping, and this would have caused her concern and worry. The pain would have been experienced daily while Mrs E was mobilising. For these reasons, we have found that the impact we have linked to the failing fits with level 2. The recommended financial remedy for level 2 is between £100 and £450.

49. We also review similar cases where the person has experienced similar injustice, along with our severity of injustice scale, to ensure our recommendations are consistent. Following this review, we consider the Trust should pay Mrs E £400 in recognition of the pain, distress, and inconvenience that she suffered whilst she was mobilising on the zimmer frame. This payment should be made to Mrs E within 30 days of us issuing this report. We also request the Trust provides us with evidence of the payment being made at the time the payment is made.

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