11. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
12. Mr U explained that R’s bedsheet needed changing on 2 June 2019. The HCA changing the bedsheet asked R to move in a way which caused him pain. The HCA continued to try to move the bedsheet. This caused R further pain, bringing tears to his eyes.
13. Mr U further explained another HCA intervened and the bedsheet was then changed in a way which did not cause R any pain.
14. Mr U says R had not experienced any pain while in traction, despite bedsheet changes and bed baths, prior to this. R’s body had remained straight and parallel to his leg, but when the HCA was changing the bedsheet, R had been made to sit at an angle.
15. R had an X-ray on 6 June 2019. Following this, and the discussion of his case at the trauma meeting, the decision was made for R to be transferred to Hospital B as the fracture was not healing as expected.
16. The Trust’s response, dated 29 July 2019, explains the method used to change R’s bedsheet was not inappropriate, however, it was a method R was not used to and it did cause him discomfort. The Trust apologised for this, and said it was discussed with the staff team on nightshift, and again at shift handover, to ensure the team were all aware of the method of changing bedsheets that R found the most comfortable.
17. The Trust response also explains the Consultant for Orthopaedics had reviewed R’s case notes and X-rays, and said it was highly improbable the incident caused the fracture not to heal as expected.
18. Our clinical adviser explained the treatment options for R would have been surgery or the use of traction. Traditionally splints have always been used on this type of fracture, but surgery is becoming more common, especially for older children.
19. There are no national guidelines relating to the use of traction or surgery, but our adviser agrees that traction was an appropriate treatment method in R’s case.
20. The first X-ray (23 May 2019) and the third X-ray (6 June 2019) show a similar alignment of the bone. In both X-rays, the displacement of the bone can be clearly seen. The second X-ray was taken shortly after the Thomas splint was fitted and shows the femur is straight.
21. The clinical adviser explained, when using traction, there is the possibility the muscles around the bone will pull the bone back into the position of the break meaning surgery will be required.
22. They further explained it is highly unlikely the bedsheet change would cause the bone to displace, although a bed change could cause pain if R’s leg was not supported. This is evidenced in R’s medical records, which show R reported little pain. His pain scores were generally 0/10 and at times he refused pain relief. However, following the bedsheet change on 2 June 2019, R’s pain score is documented as 2/10. Though it was later reported that R said he was not in pain.
23. In the absence of clinical guidelines or standards about the use of a Thomas splint and the potential risks, we have taken the clinical adviser’s extensive knowledge and experience into consideration. The adviser explained it is likely the bone reverted to the injury alignment either shortly after the splint was applied, or it displaced as part of a gradual drift over the two weeks, which is a possibility when treating a fracture with traction.
24. Taking into consideration the information provided by Mr U, the Trust, and clinical adviser, we conclude that although the bedsheet change did cause discomfort and pain to R, which the Trust have acknowledged and apologised for, it is unlikely this caused the displacement of the fracture and the need for surgery.