Injury diagnosis
27. Ms E complains that the ambulance crew misdiagnosed her injury.
28. Our Paramedic Adviser said ambulance crews are not expected to definitively diagnose a patient’s illness or injury unless it is obvious. Experience and theoretical knowledge support them to list possible conditions that could be causing the patient’s symptoms. This lets the ambulance crew decide whether a patient needs immediate transport to hospital, referral to another health care professional, or delayed treatment either at home or by a GP.
29. Section 4 of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK Ambulance Service Clinical Practice Guidelines 2016 (the Guidelines) advises that a ‘Primary Survey’ (airway, breathing, circulation) should be done to identify whether a patient has a life threatening, time dependent injury. This is followed by a ‘Secondary Survey’ which includes a head to toe assessment, and consideration of how the injury happened, to decide which areas of the body are likely to have been injured.
30. The ambulance crew (the Paramedic and the Emergency Care Support Worker) did a primary survey, in line with the Guidelines. Ms E was breathing, had a pulse rate, and her injury was not time critical. The ambulance crew then attempted a secondary assessment. The clinical records suggest that Ms E was un-cooperative, anxious, distracted, and in an altered mental state meaning a structured head to toe assessment was difficult.
31. The Paramedic Adviser said that assessments need to be adapted to the circumstances, and as Ms E was complaining about pain in her right thigh, the ambulance crew assessed her leg.
32. The ambulance crew noted Ms E had no leg deformity, was able to stand, and weight bear. They also considered the mechanism of Ms E’s injury. The Guidelines include major trauma (such as fractured hip/femur/long bone) is more likely in falls over six metres and in adults over 55. As Ms E was over 50, but not over 55 years of age, and had fallen against a cupboard, a major trauma would be unlikely.
33. The Paramedic Adviser said that there was little evidence to suggest a diagnosis of a fracture, and the ambulance crew noted ‘low likelihood of # [fracture] to leg’. The Paramedic Adviser said this was an appropriate conclusion. Their decision to take Ms E to hospital for further assessment and X-ray was also correct.
34. We can understand Ms E’s concern that the ambulance crew did not diagnose a hip fracture. While the ambulance crew was not able to do a full secondary assessment, they appropriately assessed her right leg and did not find any indication of a fracture.
35. We find there were no failings in the ambulance crew’s assessment of Ms E’s injury. Therefore, we do not uphold this issue of complaint.
Pain assessment, pain scoring, and analgesia (pain relief)
36. Ms E complains that the ambulance crew failed to adequately assess her pain and that this meant they did not take her injury seriously.
37. The ambulance crew noted ‘Pt lying on floor. Complaining of leg pain’ and ‘Pt complaining of front R[ight] thigh pain’. The Guidelines recommend that all patients with pain should have the severity of their pain scored. However, the Guidelines also recognise that pain, ‘scoring will not be possible in all circumstances (e.g. cognitively impaired individuals, communication difficulties, altered level of consciousness) and in these circumstances behavioural cues will be more important in assessing pain’.
38. The ambulance crew provided statements during the Ambulance Trust’s investigation of Ms E’s complaint. They detailed the problems they had assessing Ms E’s pain. The Emergency Care Support Worker said Ms E ‘started to become very agitated and shouting out not listening to reason’. The Paramedic said Ms E ‘was unwilling to engage with the crew’ and ‘was very reluctant to stay still’.
39. Ms E was in pain and distressed, and we can also see that it was difficult for the ambulance crew to assess the level of her pain. The ambulance crew also noted they were given information that ‘… pt has Hx [history] of faking injuries + injuries not consistent with mechanism’. This information introduced an element of doubt about Ms E’s injury and pain. This is supported by the ambulance crew’s further note that, when assisting Ms E to the ambulance, she was ‘Stating throughout, “You don’t believe me, no one believes me”’.
40. Having considered the evidence, we are unable to reach a finding about whether the ambulance crew did all they could to assess Ms E’s pain (in line with the Guidelines) in what were difficult circumstances, or if they were unduly influenced by the information given to them about Ms E’s history.
41. Ms E also complains that the ambulance crew did not record her pain score, despite giving her pain killers. This resulted in her not being given adequate pain relief.
42. The Guidelines recommend that pain relief should normally be given in an incremental way. The ambulance crew acknowledged Ms E was in pain and gave her paracetamol (used to treat mild to moderate pain). The Paramedic Adviser said that paracetamol is an acceptable medication to give as a first step.
43. The Emergency Care Support Worker said Ms E became very agitated during their assessment of her leg, so the mental health crisis team (who were also present) gave her a light sedative. This was Ms E’s own medication, promethazine.
44. The Guidelines advise that all patients should have the severity of their pain scored after each intervention (such as giving a pain killer). The ambulance crew did not record a pain score for Ms E after giving her paracetamol, or after the mental health crisis team gave her promethazine. The guidelines allow the omission of pain scoring under certain circumstances (see paragraph 37). We can see from the records that Ms E was distracted, and the ambulance crew reported she would not engage with them. This meant that the ambulance crew were unable to score her pain. The Paramedic Adviser said under such circumstances, behavioural clues to Ms E’s pain were important.
45. The Paramedic Adviser said she would have expected the ambulance crew to have been assessing Ms E’s pain level both visually and verbally during the journey to hospital. However, we have seen no record that the ambulance crew did this.
46. Ms E was distressed, worried, and in pain and her response to this meant the ambulance crew had difficulty in scoring her pain. The guidelines recognise that such circumstances can occur. However, in the absence of pain scoring, the ambulance crew did not record the effect (if any) of the pain relief on Ms E’s behaviour, so we have no evidence they were looking for behavioural clues.
47. Ms E was agitated and continuing to complain of pain, yet we have seen no evidence of the ambulance crew considering giving her stronger pain relief.
48. Having considered the available evidence, we find that, on balance, the ambulance crew failed to consider other methods of scoring Ms E’s pain to assess the effectiveness of the pain relief and sedation she had been given. This meant they did not give her adequate pain relief.
49. In summary, we have been unable to reach a finding about the ambulance crew’s initial assessment of Ms E’s pain. We have found that they did not assess the effectiveness of the pain relief and sedation given to Ms E, nor give her adequate pain relief. We therefore partly uphold this aspect of Ms E’s complaint about the Ambulance Trust.
Ms E making her way down the stairs
50. Ms E complains that the ambulance crew treated her very cruelly by insisting she walk down the stairs.
51. The Paramedic Adviser said ambulance crews are trained to carry out a dynamic manual handling risk assessment before moving patients. The records show Ms E was mobile and able to weight bear. She was standing and sitting of her own accord. The mechanism of injury did not suggest major trauma, and the assessment did not indicate any serious injury.
52. In a statement made during the Ambulance Trust’s handling of Ms E’s subsequent complaint, the Paramedic wrote, ‘She asked to be carried down the stairs and we explained that because her stairs were narrow, steep, curved, with no railing for half the length and with her being unwilling to remain still it would be quite dangerous for us to carry her down the stairs’. It is apparent that the ambulance crew were very concerned about the layout of Ms E’s home and how they could get her safely down from the bedroom.
53. The records show that Ms E was anxious (continuously grabbing out at the crew) and apparently uncooperative. The ambulance crew recorded that Ms E ‘keeps standing self up after sitting down’. Ms E told us she could not stay still because of the pain she was in. However, the ambulance crew had to get Ms E, and themselves, safely downstairs. They decided they could not do this carrying Ms E in a chair. There was no evidence of a fracture, so the ambulance crew asked her to make her own way down the stairs, with their help.
54. There are no specific guidelines relevant to this aspect of Ms E’s complaint. However, the Paramedic Adviser said that in the circumstances, if the ambulance crew had carried Ms E down on a chair this would have placed both them and Ms E at risk. Based on the evidence available to them at the time, it was reasonable from a safety point of view, for the ambulance crew to ask her to make her own way down the stairs with their help. We therefore find there was no failing, although we recognise the pain and distress Ms E felt. We do not uphold this aspect of the complaint.
Ambulance Trust responses to Ms E’s complaints
55. Our Principles of Good Complaint Handling say that public bodies should investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence. Ms E complains that some of the Ambulance Trust’s responses are inaccurate, and this has caused her additional distress.
56. Ms E complained to the Ambulance Trust about the attitude and behaviour of the ambulance crew who attended on 16 March 2018. She said they treated her roughly, pulling her up from the floor, and laughed at her. Ms E was particularly concerned the ambulance crew insisted she make her own way down the stairs.
57. The Ambulance Trust investigated and obtained statements from both members of the ambulance crew, demonstrating thoroughness. This was in line with our Principles of Good Complaint Handling.
58. But we can see that Ms E’s account of events and the ambulance crew’s statements differ on the extent of Ms E’s mobility, physical handling, pain level, and whether the ambulance crew laughed at Ms E.
59. The Ambulance Trust explained to Ms E why the crew did not carry her down the stairs. It added that the ambulance crew regretted not carrying her down the stairs but believed that by encouraging Ms E to make her own way down they were safeguarding both their own and her safety. The Ambulance Trust said that, as a result of Ms E’s complaint, the ambulance crew would in future be more aware of unexpected presentations of serious injuries. This was appropriate.
60. The Ambulance Trust also noted that the ambulance crew failed to record a pain score, even though Ms E had been given pain relief. This was accurate but no explanation was provided.
61. With regard to Ms E’s concern that the ambulance crew had been laughing at her, the Ambulance Trust said this highlighted the importance of staff maintaining a professional demeanour even when not in the immediate presence of the patient. While this is accurate, we would expect the Ambulance Trust to have provided more detail and explanation.
62. The Ambulance Trust apologised that the care Ms E had received fell below the standard she was expecting, and for the distress caused. The Ambulance Trust also told Ms E that the ambulance crew had reflected on their actions. This was appropriate.
63. We have found no inaccuracies in the Ambulance Trust’s response to Ms E’s complaint. The response was based on the available facts and evidence, in line with our Principles of Good Complaint Handling. However, it would have been more customer-focussed if the Ambulance Trust had given more detailed explanations. We do not uphold this aspect of Ms E’s complaint.
Dartford and Gravesham NHS Trust
Hip fracture diagnosis
64. Ms E complains that two Emergency Department doctors failed to diagnose that she had fractured her right hip.
65. X-rays of Ms E’s right femur (thigh bone) were taken on 16 March. A junior doctor and an ED consultant checked the X-rays, found no fractures, and Ms E was discharged the next morning.
66. The ED Adviser explained that the standard method of examining a musculoskeletal injury in the Emergency Department is to use the ‘look, feel, move’ system (FitzSimmons CR, Wardrope J Assessment and Care of Musculoskeletal Problems https://emj.bmj.com/content/22/1/68). Ms E’s medical records show that Emergency Department staff appropriately used this system when examining Ms E’s leg on 16 and 17 March. However, the ED consultant’s examination on 17 March was limited because of the pain Ms E was in.
67. The ED Adviser said that the ED doctors’ assessments, and the investigations they ordered on both days were in line with GMC Good Medical Practice, which includes that doctors must:
a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary.
68. Our ED Adviser reviewed Ms E’s X-rays from 16 March. He said there is a line on the anteroposterior (from front to back) view of the right femur representing an undisplaced fracture of the bones of the neck of the femur (there is a crack in the bone – but no movement of the bones around the fracture - at the top end of the femur).
69. The ED Adviser said it is understandable that the fracture was missed – it is undisplaced and follows the normal anatomy of the intertrochanteric line (a ridge normally present on the femur).
70. The ED Adviser added that it is standard practice in the UK for all Emergency Department X-rays to be reviewed and reported on by a radiologist (specialist in interpreting X-rays), within two to three days of the patient’s attendance, because fractures such as Ms E’s can be missed.
71. Ms E was readmitted, within a few hours of being discharged, on 17 March because of the continuing pain in her right leg. The ED consultant noted: ‘I met this lady yesterday here. Examined her legs again today – NAD [no abnormality detected] (exam limited by pain) will r/v [review] after analgesia. … Pt. medically fit for psych assess’.
72. A psychiatric liaison nurse (PLN) assessed Ms E that day. Ms E described her pain as excruciating, and the psychiatric nurse noted Ms E was emotional and distressed but fully orientated, articulate, and had full insight and capacity. The psychiatric nurse discussed Ms E with the ED consultant who said Ms E had soft tissue damage - nine X-ray images had been taken and no abnormality detected. The psychiatric nurse noted: ‘I pressed him about the remarkable swelling [of Ms E’s right leg] and inability to stand or walk. Dr … said this was because she was declining analgesia. I advised that I could not clear [Ms E] for discharge with such significant physical distress and requested he review the case’.
73. The ED consultant subsequently noted: ‘17.41 The pt. is still in a lot of pain. She won’t allow me to fully examine her R [Right] leg due to pain. PLN … is concerned that her complaint of pain is not due to mental health illness. X rays from yesterday not yet reported’. The consultant queried whether Ms E had a hip fracture (‘?Intertrochanteric #’) and ordered a CT scan of Ms E’s right hip. This showed a fracture of the femur.
74. The ED adviser explained that if there is concern that there might be a hip fracture, such as continuing pain, but the X-ray is considered to be normal, further imaging should be done. NICE CG124 says that doctors should ‘Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative X-rays of the hip of an adequate standard’.
75. Ms E was in great pain when readmitted. When the ED consultant first saw Ms E during this admission, his examination of her leg was limited by Ms E’s pain. He intended to review her again after she had had pain relief. However, Emergency Department staff failed to consider that the continuing pain, its level, and the swelling, might be due to a hip fracture. As such, they did not order a CT scan until the psychiatric nurse intervened. This was not in line with NICE CG 124.
76. In summary, clinical advice is that it was understandable the fracture was missed on the initial X-ray. However, following Ms E’s readmission, ED staff did not assess or take sufficient account of her pain to consider whether there was a hip fracture or order a CT scan. This was a failing. Ms E told us that besides the physical distress, she suffered emotional distress as staff did not believe the amount of pain she was in until the psychiatric nurse assessed her. We uphold this aspect of Ms E’s complaint.
Knee splint application
77. A cricket pad splint is used following a knee injury. It immobilises the knee joint, supports the knee and helps the patient to walk. The ED Adviser said that there is no record in Ms E’s notes of the decision to apply a cricket-pad splint, or justification for it as there was no record of knee injury or knee pain.
78. Ms E complains the member of nursing staff (the Nursing Associate) who applied the cricket pad splint to her knee on 16 March manipulated her leg roughly, and more than necessary, causing great pain.
79. In its response to Ms E’s complaint, the Hospital Trust said, ‘there is no evidence or witness to any manipulation in the Emergency Department’. Our Nurse Adviser said a cricket splint is slid underneath the knee and the straps placed around it. Applying the splint involves some lifting of the leg, and therefore manipulation of the hip joint.
80. Ms E is clear that the Nursing Associate manipulated her leg more than necessary during the splinting process, causing her pain. The Nursing Associate made no record of the process, contrary to NMC guidance. We have considered the available evidence and find, on balance, that it is more likely than not that Ms E’s leg/hip joint was manipulated more than necessary to apply a splint that we have seen no justification for. This was a failing.
81. Ms E also complains that the Nursing Associate continued to apply the splint, despite Ms E telling her several times to stop. The Nursing Associate then asked a security guard to hold Ms E down so she could complete the splinting.
82. The NMC’s ‘Standards of proficiency for nursing associates’ says that registered nursing associates will be able to understand and act in accordance with the NMC Code and understand and apply relevant legal, regulatory and governance requirements.
83. The NMC Code includes ‘10.1 complete records at the time or as soon as possible after an event’. The Nursing Associate made no record in Ms E’s notes of her application of the splint and this was not in line with the NMC Code. What the Nursing Associate did do is make a written report of the incident (anonymised, via the Datix incident reporting system) the next day entitled ‘assault on staff by patient’. The Nursing Associate wrote that [while they were applying the splint] Ms E had pulled on their arm aggressively causing bruising and lacerations.
84. The security guard also wrote a Datix entry stating: ‘Called by sister and asked for a hand with a difficult patient, to assist staff putting on a s[p]lint on a patient which had been lashing out and kicking nursing staff … staff had half done putting on the s[p]lint and to complete the job I prevented the female lashing out by cradling her arms …’.
85. During the Hospital Trust’s handling of Ms E’s complaint about her care, the Nursing Associate stated: ‘At no point was Mrs … [Ms E] forcibly held down on to the bed … [Ms E] by this point had several security guards by her side. She remained still enough to put the brace on, there was obvious discomfort …’.
86. The NMC Code says that nurses must ‘4.3 keep to all relevant laws about mental capacity …’. The Nurse Adviser said the first key principle of the Mental Capacity Act (2005) is to assume that all people have the capacity to make their own decisions unless proven otherwise. There is no documentation at the time of this incident that Ms E did not have capacity to consent and make her own decisions for treatment, including the right to withdraw consent at any time.
87. The NMC Code says that nurses must ‘4.2 make sure that you get properly informed consent and document it before carrying out any action’ and ‘4.1 balance the need to act in the best interest of people at all times with the requirement to respect a person’s right to accept or refuse treatment’. The Nurse Adviser explained that Ms E had the right to refuse treatment and the Nursing Associate should have stopped applying the splint when Ms E asked her to. This did not happen.
88. Based on the evidence we have seen, it appears that Ms E was held against her will, so that the Nursing Associate could complete a procedure that Ms E was objecting to, having withdrawn her consent. This was contrary to the Mental Capacity Act and the NMC Code. This was a failing and caused great distress to Ms E. We uphold this aspect of Ms E’s complaint.
Complaint a nurse refused to help Ms E to the toilet
89. Ms E says she asked a member of ward staff (the Nursing Assistant) to help her to the toilet but the Nursing Assistant told Ms E she could manage by herself. Ms E says she could not get to the toilet in time so she ‘wet herself’.
90. The Nursing Assistant documented that she took Ms E to the toilet at 4am and in a subsequent statement said she offered to assist Ms E but was asked to wait outside the toilet. At 7.30am a nurse noted Ms E was ‘incontinent of urine. Trousers removed & clean pyjamas applied’.
91. We have considered the evidence and cannot reconcile the conflicting accounts of this incident. We are therefore unable to reach a finding on this issue.
Complaint that while Ms E was waiting in the reception area to go home, a nurse confronted her, alleging that Ms E had scratched her arm during the splinting process
92. Ms E says that while she was waiting in the lounge for transport home on 17 March the Nursing Associate confronted her, saying Ms E had scratched her arm.
93. The Nursing Associate provided a statement during the Hospital Trust’s investigation of Ms E’s complaint. She said that her last involvement with Ms E was putting the cricket splint on her.
94. Ms E has told us of the distress the incident caused her, but we cannot reconcile the conflicting evidence relating to this incident. We are therefore unable to reach a finding about this aspect of Ms E’s complaint to us.
Discharge from the Emergency Department
95. Ms E complains that staff discharged her during the morning of 17 March despite her severe pain.
96. The RCEM Management of Pain in Adults recommends that pain is assessed, usually with a pain score, within 20 minutes of arrival in the Emergency Department. It then recommends that pain relief is given according to the patient’s pain level, as determined by the pain score. The effectiveness of the pain relief should be re-evaluated within an hour.
97. The Nurse Adviser said the first opportunity for a pain score would be during triage (patient pre-assessment by a nurse or doctor before further action is taken), yet the relevant box for this is blank. A pain score would also usually be recorded on a patient’s National Early Warning Score (NEWS) chart (a system of standardised assessment and response to acute illness). There is no NEWS chart for Ms E on 16 March. The patient’s safety bundle, which also gives prompts to assess analgesia, was not completed at any point during Ms E’s Emergency Department admission. There is no record in Ms E’s notes of staff assessing her pain level at any time during this Emergency Department attendance, contrary RCEM guidance.
98. Ms E was admitted on 16 March and discharged the next morning. At about 6.15pm the Nurse Associate manipulated Ms E’s leg when applying a knee splint, yet Ms E was not given any pain relief until 6.50pm (oral ibuprofen and oramorph). This was over three hours after she arrived, and despite her repeated documented complaints of pain and requests for help. Ms E was then only given prescribed analgesia sporadically. Staff were not giving her pain relief according to her pain level, contrary to RCEM guidance. The last dose of oral paracetamol was in the morning of the 17 March. There is no evidence of staff assessing Ms E’s pain before discharging her.
99. The ED Adviser said as staff did not score Ms E’s pain, we cannot know whether they gave her appropriate and effective analgesia. However, given that Ms E had a fracture of her hip, it is highly likely that she was in severe pain and, according to the RCEM Management of Pain in Adults, she should have been given stronger pain relief, such as intravenous morphine.
100. The ED Adviser said the decision to discharge Ms E from the Emergency Department was made because staff did not identify a significant injury when they assessed Ms E and took X-rays. If there is concern that there might be a hip fracture, such as continuing pain, but the X-ray is normal, further imaging such as a CT scan should be done. Ms E’s ED records show that she had ongoing pain in her right hip, so staff should have suspected a hip fracture and ordered a CT or MRI scan, rather than discharging her.
101. Despite remaining in the Emergency Department for over 14 hours after the X-ray was reviewed by the Emergency Department doctor, no further medical assessment took place. No pain assessment was recorded during this time.
102. From the evidence we have seen, it is apparent that Ms E’s pain was not properly assessed or managed during her first ED admission. Her complaints of continuing and severe pain should have led staff to consider whether she had a hip fracture, and to order a CT scan to assess whether she did. Her discharge was neither safe or appropriate. This was contrary to relevant guidance and was a failing.
103. Ms E says she was greatly distressed by the events and is concerned that the delay in identifying the fracture, because she was discharged, meant her hip joint was damaged further. We have considered whether the failings we have identified had an impact on Ms E’s long term outcome. The decision to discharge Ms E delayed the diagnosis of her hip fracture, and led to consequent pain and suffering of trying to manage at home with a broken hip. However, the ED Adviser said there is no evidence that the delay in diagnosis led to any other adverse outcome. Ms E’s hip fracture required an operation to fix it, and neither the need for an operation, or its type, changed as a result of the decision to discharge her from the Emergency Department during the morning of 17 March.
104. Based on the evidence we have seen we uphold this aspect of Ms E’s complaint.
The Hospital Trust’s responses to Ms E’s complaints
105. Ms E complains that the Hospital Trust’s responses to her complaints were inaccurate.
106. Our Principles of Good Complaint Handling say that public bodies should investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence.
107. Ms E emailed the Hospital Trust on 3 and 8 May 2018 to complain about her care and treatment.
108. The Hospital Trust wrote to Ms E on 21 November 2018. It explained:
· as Ms E had been agitated, she was moved to a room to wait for an assessment by the psychiatric liaison team – and was seen throwing herself on to the floor.
· Two Emergency Department doctors reviewed Ms E’s X-rays and documented that there was no fracture.
· Nursing staff did not forcibly hold Ms E down to apply a splint.
· There was no evidence of physical manipulation whilst Ms E was in the Emergency Department.
· The delay in diagnosing the hip fracture did not cause the shortening of Ms E’s leg – this was caused by the fracture configuration and quality of the bone.
· Nursing staff did not tell Ms E to walk to the toilet – she was wheeled there and offered help – which she declined.
109. Ms E emailed the Hospital Trust on 23 November 2018. She questioned the accuracy of the Hospital Trust’s response. Ms E said it was not true a nurse had helped her to the toilet, she was told to walk. Ms E complained the Trust had not fully answered all her questions, including the doctor moving her trolley up and down. Ms E also disputed she had been throwing herself on the floor and that the nurse and a security guard had not held her down. Ms E said she was appalled the Trust made ‘such a huge reference to my mental health’ and should not have made so much of how her accident happened. Ms E also complained staff had not completed a pain score chart.
110. Ms E told us that she did not throw herself on the floor because she was in too much pain from her hip to have done this. We are unable to reconcile the conflicting accounts and therefore cannot reach a finding as to which is accurate.
111. The Hospital Trust said that nursing staff did not hold Ms E down on the bed so that a splint could be applied. We can see that the Hospital Trust obtained a statement from the Nursing Associate who applied the splint. However, we have seen no evidence that they asked the security guard what happened or accessed their Datix report of the incident. The security guard reported that they were asked to help a member of nursing staff, who was putting a splint on Ms E, as Ms E had been lashing out and kicking nursing staff. The security guard wrote that they had cradled Ms E’s arms so the nurse could continue applying the splint. Technically, the Hospital Trust’s response was accurate in that a member of nursing staff did not hold Ms E down, as it was a member of security staff. Nevertheless, this issue should have been investigated more thoroughly to establish the facts of what happened including that the Nursing Associate continued to treat Ms E after she had withdrawn her consent.
112. The Hospital Trust said there was no evidence of physical manipulation while Ms E was in the Emergency Department. Our Nurse Adviser explained that applying a cricket splint would involve some lifting of the leg and therefore manipulation of the hip joint. In addition, the Hospital Trust failed to identify that there was no rationale for applying the cricket splint in the first place. Based on the evidence we have seen; we find the Hospital Trust’s response to this issue was inaccurate.
113. The Hospital Trust said that the delay in diagnosing Ms E’s hip fracture did not cause the shortening of her leg. Our ED Adviser agrees. We find the Hospital Trust’s response to this issue was accurate.
114. Finally, regarding Ms E’s complaint that nursing staff refused to help her to the toilet, the Hospital Trust said that a member of staff wheeled Ms E to the toilet and offered to help but this was declined. We have considered this issue and cannot reconcile the conflicting accounts. We are unable to make a finding with regard to the accuracy of the Hospital Trust’s response to this issue of complaint.
115. In summary, we can see that some of the Hospital Trust’s responses to Ms E’s issues of complaint were accurate. There are other issues where we have been unable to reach a view, as there are conflicting accounts of what happened. And finally, there are two issues of complaint, Ms E being held down and her leg being manipulated, where we have found the Hospital Trust’s responses were inaccurate and omitted relevant information. We therefore partly uphold Ms E’s complaint about the accuracy of the Hospital Trust’s responses.