Initial diagnosis
19. Mrs N complains the Trust delayed diagnosing Mrs L’s broken left hip. She says the Trust should have diagnosed this straight away. She says that her mother remained in pain and the Trust missed an opportunity to provide treatment for her.
20. The Trust have apologised for the delay in diagnosing Mrs L’s broken left hip. It says, on admission, Mrs L complained of knee pain and was holding her left knee in flexion (her leg was bent).
21. GMC Guidance says: ‘15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you 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 c) refer a patient to another practitioner when this serves the patient’s needs’
22. The emergency department attendance summary states Mrs L was complaining of pain in her knee. She had also been incontinent of urine for a few weeks.
23. The Trust ordered an X-ray to examine Mrs L’s knee as this is where she was complaining of pain. It did not X-ray her hip.
24. On 30 March, the records show the Trust noted nothing obvious with Mrs L’s left knee. The notes state the left knee was able to full straighten passively when distracted. The Trust noted impressions of a kidney infection, likely urinary tract infection (UTI) and soft tissue knee injury.
25. The records show on 1 April, the Trust admitted Mrs L to the Acute Medical Unit. The Trust’s initial diagnosis and treatment plan was to manage and treat the acute kidney infection. This is because an infection can be serious for people who have a diagnosis chronic kidney disease.
26. Mrs L underwent a second left knee X-ray at the Trust on 2 April. The medical records state that on 3 April, the X-ray did not show a definite injury.
27. The records show on 4 April, Mrs L’s kidney infection was worsening.
28. Our orthopaedic adviser says, as per GMC good medical Practice, the Trust did adequately assess Mrs L, and ordered relevant investigations based on what she had advised on admission.
29. The NHS overview and the British Medical Journal does not list knee pain as an indication of a hip fracture. The NHS overview states: ‘Symptoms of a hip fracture after a fall may include: • pain • not being able to lift, move or rotate (turn) your leg • not being able to stand or put weight on your leg • bruising and swelling around your hip • your injured leg appearing shorter than your other leg • your injured leg turning outwards’
30. The Trust did miss the fracture in Mrs L’s hip. The Trust have acknowledged this in hindsight. We have seen on admission, the Trust promptly ordered suitable investigations for Mrs L’s symptoms, in line with GMC Good Medical Practice. It investigated the knee pain and ordered an X-ray to help with diagnosis. Hip fracture guidance does not include that knee pain is a symptom of a hip fracture. The Trust also assessed her incontinence and diagnosed an acute kidney infection. The notes say her kidney infection worsened, and therefore was the priority.
31. We understand that Mrs L was in pain and how challenging it must have been for Mrs N to witness this. We consider the Trust took the correct steps to investigate the symptoms Mrs L presented with in the emergency department, in line with GMC guidance. It was unfortunate that the X-ray was only limited to her knee because of the description of symptoms given by Mrs L. The Trust have acknowledged this as a missed opportunity. However, the care did not fall so short that it would be considered a failing. This is because the Trust appropriately investigated the symptoms Mrs L presented with. There is no failing in the initial assessment and treatment of Mrs L in the emergency department.
Failed to undertake further tests
32. Mrs N complains the Trust failed to undertake further tests between 29 March and 17 April, to diagnose Mrs L correctly with a hip fracture. Mrs L remained at the Trust for three weeks before the correct diagnosis was made. Mrs N says her mother remained in pain and discomfort prior to being correctly diagnosed.
33. The Trust says Mrs L was admitted to the Acute Medical unit as she had been diagnosed with an acute kidney infection. A physiotherapist completed an initial assessment to establish her rehabilitation requirements.
34. It is important to treat a kidney infection, especially in older people. This is because an infection can cause a lack of blood flow to the kidneys and cause damage to the kidneys. As Mrs L had a diagnosis of chronic kidney disease, this could make this more serious.
35. The records show Mrs L was diagnosed with an acute kidney infection and anaemia (deficiency in the number or quality of red blood cells). She also continued to present with knee pain between 29 March and 17 April.
36. On 2 April the physiotherapist documented that they were unable to assess Mrs L’s physical ability. This would have included joint range of movement or muscle strength due to the pain that she reported in her left knee. The physiotherapist documented that they would review her, following her X-ray results.
37. On 3 April, the X-ray did not show a definite injury to Mrs L’s left knee. On 4 April, it is recorded that her acute kidney infection was worsening. Therefore, the kidney infection was a priority.
38. On 4 April, the physiotherapists carried out a functional assessment. The records show that Mrs L reported to the physiotherapists weakness in her left leg and pain in her left knee. The physiotherapists also documented that she had good muscle strength present within her hip muscles in both legs. Mrs L completed a sit to stand and took a few steps with a rollator frame and assistance of one person. On the second attempt she was unable to lift her left foot. The physiotherapist documented that Mrs L was in a lot of pain, presented as being anxious, and that they would review in the morning.
39. The records show that the physiotherapy team attempted to see Mrs L on the 8 April and 16 April, however she refused.
40. The records show that Mrs L’s anaemia proved resistant to treatment, so the Trust investigated further. On 15 April, an OGD was requested by the Trust to review the cause of the anaemia.
41. On 17 April, the records show that the OGD found she had CKD (chronic kidney disease) stage 3, meaning moderate kidney damage. At stage 3, your kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant. The records show that this was also when the Trust discovered her fractured hip.
42. GMC Guidance says: ‘15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you 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 c) refer a patient to another practitioner when this serves the patient’s needs’
43. Our orthopaedic adviser says, based on her symptoms, Mrs L should have been placed under a medical team not an orthopaedic team. This is because the acute kidney infection was a priority due to the possible damage it could cause to her kidneys. The decision to refer her to another practitioner which served her needs was line with GMC guidance.
44. The results from the investigations indicated that Mrs L’s admission to the acute medical unit, to treat her acute kidney infection, was the correct decision. As the X-ray had showed nothing of concern in her knee, referring her to an orthopaedic practitioner did not serve the patient’s priority need.
45. Chartered Society of Physiotherapy Code says: ‘Principle 1 – CSP members take responsibility for their actions.
• 1.1.6 Justify an account for their decisions and actions, including decisions not to act.’
46. Chartered Society of Physiotherapy Quality Assurance Standards says: ‘Record keeping and information governance 6.1 – Every service user who receives physiotherapy has an appropriate record’
47. Health and Care Professions Council Standards says: ‘4 – be able to practise as an autonomous professional, exercising their own professional judgement’ ‘10 – be able to maintain records appropriately’
48. The records show that the Trust did not diagnose Mrs L’s hip fracture due to the symptoms she presented with and the pain she described. She continued to present with left knee pain between 29 March and 17 April. The Trust provided Mrs L with physiotherapy for her knee pain throughout this period.
49. Our physiotherapy adviser says, during Mrs L’s four physiotherapy sessions, the physiotherapist has clearly documented their decisions and reasons for their actions, demonstrating good clinical practice. The evidence shows that the physiotherapists did provide appropriate therapy within the four documented sessions, given the symptoms that Mrs L presented with.
50. In line with the Code, quality assurance standards, and the Health and Care Professions Council standards, the physiotherapist has documented clinical decisions regarding each session. They have used their own professional judgement in order to reason their practice and justify their decisions.
51. We asked the physiotherapist adviser if the Trust should have made further recommendations or requested further investigations based on the physiotherapy sessions. The physiotherapist adviser says the symptoms that Mrs L presented with, a painful left knee and an inability to straighten her knee, were not in keeping with the normal symptoms for a hip injury.
52. The NHS website states: ‘Symptoms of a hip fracture after a fall may include: • pain • not being able to lift, move or rotate (turn) your leg • not being able to stand or put weight on your leg • bruising and swelling around your hip • your injured leg appearing shorter than your other leg • your injured leg turning outwards’
53. The British Medical Journal states: ‘Key diagnostic factors: • history of fall or trauma • pain in the affected hip, groin, or thigh • inability to bear weight or move the hip • shortened, externally rotated leg’
54. The NHS and BMJ guidance do not list knee pain as a symptom of a fractured hip.
55. We understand it must have been upsetting to discover Mrs L had been in pain and had a broken hip for three weeks before it was diagnosed. We have seen the Trust appropriately referred Mrs L to the medical unit to treat her acute kidney infection as this was the priority. The Trust also investigated Mrs L’s knee pain and provided support and physiotherapy for this. Physiotherapy was provided in line with national guidance, and Mrs L did not indicate any symptoms of hip injury.
Complaint handling
56. Mrs N complains the Trust took too long to respond to her complaint. She says the Trust did not come to a final resolution until one year and four months after the first complaint had been made. Mrs N was frustrated with the time taken.
57. The Trust have apologised for the delay in providing a response and they acknowledged it has been a very difficult and stressful time for Mrs N. The Trust added the COVID-19 pandemic contributed to delays.
58. The Trust confirm on its website that it follows the national guidance for NHS complaints.
59. The NHS website, how to complain to the NHS, sets out what to expect. It states: • ‘You should expect an acknowledgement and the offer of a discussion about the handling of your complaint within 3 working days of receiving your complaint.
• If you accept, the discussion will cover the period within which a response to your complaint is likely to be sent.
• There's no set timeframe, and this will depend on the nature of your complaint.
• If, in the end, the response is delayed for any reason, you should be kept informed.
• If you made a complaint but do not receive a response or decision for more than 6 months, you should be told the reason for the delay.’
60. Mrs N raised her complaint on 5 June 2019. This was acknowledged by the Trust on the same day. This is in line with the guidance above. The Trust asked for written permission from Mrs L to begin its investigations. On 19 June Mrs N asked if this could be completed without written consent.
61. Mrs N emailed again on 28 June and 9 July. The Trust responded on 10 July to advise that the complaint handler had been away on annual leave. Mrs N added further concerns to her complaint on 10 July and requested a response. She emailed the Trust on 17 July and asked the Trust to let her know if there was a timescale for her to receive a response.
62. Mrs N emailed the Trust on 5 August to advise that Mrs L had died. She requested a timescale for her to receive a response to her complaint. Mrs N emailed the Trust on 7 August as she had not received a response. The Trust responded the same day to apologise for the delay in providing a response. The Trust said it wanted to ensure that every concern she had raised was addressed in full. NHS guidance says there is no set timeframe as this will depend on the nature of the complaint.
63. The Trust contacted Mrs N on the phone in August to advise a meeting had been set up internally to discuss her complaint. The Trust advised her a further internal meeting would take place in September.
64. Mrs N emailed the Trust on 9 October requesting an update as she had not been contacted since the Trust’s phone call in August. The Trust emailed her the same day to advise that a further meeting was being arranged and a written response would be provided.
65. The Trust emailed her on 5 December saying the matter was still under investigation. The Trust apologised for the delay and said the outcome would be shared with her as soon as possible. In line with NHS guidance, Mrs N was informed the Trust’s response had been delayed due to ongoing investigations.
66. On 7 January 2020, Mrs N emailed the Trust and highlighted that the NHS website says if a complainant does not receive a decision for more than six months they should be told the reason why. The Trust responded on the same day to apologise for the delay. The Trust explained a full review had been completed and invited Mrs N to a face-to-face meeting in February, when it would provide her with the outcome of the investigation.
67. Mrs N requested the Trust arrange the meeting during the week commencing 17 February. On 12 February the Trust contacted Mrs N to advise her the meeting would not be going ahead, and would be arranged for March.
68. As a result of COVID-19 and lockdown restrictions, no meeting was able to take place in March.
69. A telephone conference was arranged for 8 June. Following the meeting, the Trust wrote to Mrs N to summarise the meeting. The Trust advised that they were going to arrange a meeting with the clinical team to discuss the concerns that had been raised.
70. A second meeting with the Trust and Mrs N happened on 4 August, during which the Trust provided a response to her complaints. A final response letter was sent to her on 12 October.
71. Our Principles of Good Complaint Handling say in being customer focused, public bodies should do the following: • Deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.
• Acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply. Public bodies should keep the complainant regularly informed about progress and the reasons for any delays and provide a point of contact throughout the course of the complaint.
72. We understand that it was frustrating for Mrs N to have to follow up on her complaint. We also recognise the Trust was very busy and it was a complex complaint which required input from clinicians. This was explained to Mrs N, and is in keeping with our principles regarding keeping complainants regularly informed.
73. In line with our Principles, Mrs N had a point of contact throughout the complaint. On 5 June, 7 August, 9 October 2019, and 7 January 2020, she received a reply the same or next day from the Trust.
74. Mrs N says she was frustrated as she did not get answers to her concerns about her mother’s care in a timely way, and she had to follow up on what was happening with the complaint. She was seeking an apology from the Trust. The Trust responded, in line with NHS guidance and our Principles. The evidence does not show a failing in complaint handling. We are pleased to see however the Trust has apologised for the time it took to complete its complaints process on 7 August and 5 December 2019. Further apologies were issued on 7 January and 12 October 2020.