Care and treatment
20. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have seen the Trust’s actions meant Mrs U was denied the opportunity to have her operation sooner, but we have not found any indication the operation Mrs U had, could have been avoided entirely. We consider the Trust has already done enough to put right the impact of these events.
21. We appreciate the time Mrs U has spent in bringing her complaint to us and discussing her experience. We are sorry to hear about what happened and how this affected her. We are also sorry to hear about how the incident has greatly impacted on her professional and social life and understand this is frustrating.
22. Mrs U is concerned the doctor at the urgent care centre did not assess her thumb properly or provide a splint on 26 February 2021. She also says aftercare advice was not given and the Trust did not write to her GP Practice. She says this caused her unnecessary pain and frustration as her hand had to be operated on and this meant her recovery period affected all aspects of her work and social life.
23. According to General Medical Guidance, Good medical practice, domain 1 – knowledge skills and performance, ‘doctors must provide a good standard of practice and care. If they assess, diagnose or treat patients, 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 c) refer a patient to another practitioner when this serves the patient’s needs’.
24. The Trust has said within its final response dated 30 April 2021, it investigated the doctor’s examination, and accepts he should have examined the damaged tendon and movement of the thumb, but did not.
25. The Trust has apologised for this and explained it will address this with the doctor and remind them of the importance of carrying out the examination. The Trust has also said in further correspondence that if the doctor did recognise the damaged tendon a referral would have been made to the plastic surgery team.
26. Our adviser carefully considered the medical records and agrees that the doctor should have done more and confirms there is no evidence in the records that shows Mrs U’s hand was fully examined to consider a damaged tendon. They say if a person has a hand injury, they should be assessed for a tendon injury.
27. Our adviser notes despite this, carrying out an X-ray was correct and showed no bone damage or foreign body present.
28. There is no guidance which specifically lists what to check for when a person has a hand injury, the above guidance provides an overall approach clinicians should take and should be used in this instance.
29. Our adviser explains if a thorough examination had occurred, the doctor would likely have recognised Mrs U needed an operation to repair her tendon and a splint would have been provided. In this instance, he did not provide a splint as he did not correctly identify the damaged tendon.
30. Mrs U explained to us that on 28 February she had pain in her neck from the night of the fall and it was very stiff and her thumb was throbbing. At this point her main concern was her neck. She telephoned her GP on 2 or 3 March (she does not know for certain) and asked for an X-ray to be carried out on her neck. The Practice informed her it had no details of her fall and did not know about her stitches. The Practice advised her to contact A&E to arrange another X-ray and booked her in for an appointment on 8 March to remove her stitches.
31. Mrs U says on 7 March her thumb was giving her a lot of pain which can be described as a shooting pain. At this point she also noticed she could not bend her thumb and it was painful when applying pressure.
32. Mrs U’s neighbour is a consultant at a different Trust and offered to examine her thumb at home the next day. Her neighbour advised her to attend Hospital A for further X-rays of her thumb and hand, and blood tests for infection. Hospital A suspected an infection or damaged tendon and referred her to the plastics team at Hospital B.
33. The British Society for Surgery of the Hand says the surgery should be carried out within four days of the injury. It also says post-surgery, the patient should have access to a competent hand therapist who will provide support for controlled active motion rehabilitation.
34. Her surgery was done on 11 March and her arm was in a cast for 12 weeks, as well as receiving hand therapy. This is 11 days after her initial examination at the Trust.
35. This is not within the recommended timescale of four days. This delay appears to have been caused by the doctor’s inadequate examination.
36. We understand it was difficult for Mrs U to cope with her symptoms and how it affected her work and social life, and we are sorry for the distress the events complained about caused her.
37. The Ombudsman’s Principle for remedy say an appropriate range of remedies where maladministration or poor service has led to an injustice will include an apology, explanation, and acknowledgement of responsibility, revising procedures to prevent the same thing happening again and training or supervising of staff. The principles also say organisations should ensure lessons learnt are put into practice.
38. Our adviser notes it is likely the tendon was already damaged at the time of the event and that Mrs U always needed the operation to repair it. If the doctor had examined her hand appropriately, she would have been referred to the plastics team sooner. This means she may have had her surgery a few days sooner than she did.
39. We have established from the advice we have received the surgery on her hand could not have been avoided entirely due to the way in which the hand was injured, however because the doctor did not recognise the damaged tendon, Mrs U was denied the opportunity to be referred to the plastics team sooner. This prolonged her distress and pain for a few days.
40. Our adviser also explains even if she received the operation within the recommended timescale of four days she would have still needed a cast for 12 weeks and hand therapy. However, the risks of complication associated with the operation are likely to have been higher because of the delay.
41. We are unaware of any complications from Mrs U’s injury but from the information she has provided us, the adviser notes the operation she has received is usual practice for a damaged tendon.
42. To conclude, the failure to recognise the damaged tendon and delay in being referred to the plastics team did not affect the type of operation she received and the aftercare she had.
43. We acknowledge the actions of the doctor at the Trust meant she did not receive her operation within the recommended timescale of four days. We understand this will be frustrating for Mrs U to learn, we can see evidence the Trust has apologised and reflected on the incident. It has also investigated the matter with the doctor in question and raised this with them to ensure it does not happen again.
44. Mrs U has asked for a financial remedy for the surgery she needed and how this affected her life. We have seen no indication the surgery could have been prevented, only that it could have been brought forward a few days. This means Mrs U had a few days of distress and frustration which is level 1 of our Severity of Injustice Scale.
45. Following an upheld detailed investigation, we would not usually recommend financial redress for an injustice that sits at level 1 on our Scale. Because of this, we consider the Trust has already done enough to put the injustice Mrs U experienced right, and there is no basis on which for us to do anything further. We recognise this outcome may be frustrating to Mrs U, but we hope she is reassured the doctor’s actions did not cause her to require more intensive surgery than she would have otherwise needed.
Aftercare advice and discharge summary to GP Practice
46. Mrs U explains she was not given sufficient advice on how to care for her wound. She says the doctor provided her with pain killers, advised her to get her stitches removed in a week, and told her to keep it dry. She is concerned she was not given any leaflets with this information.
47. NHS website, how should I care for my stitches (February 2020) explains the following, • keep them clean and dry • watch out for any increase in redness, swelling or pain.
48. The guidance also says to contact the GP or nurse if any further assistance is required, or symptoms are noticed. It confirms removal of stitches is done by a GP or nurse and should be arranged by the patient.
49. The Trust has said within its final response clear aftercare advice should be given and has apologised if that was not the case.
50. Our adviser explains it is normal practice to have stitches removed within five to seven days for a hand injury and this is to be done by the patient’s GP Practice. Patients are expected to arrange this themselves. Similarly, if Mrs U was experiencing any pain after the event, she should arrange to see her GP as aftercare is not within the remit of an urgent care centre. The medical notes show this was documented at the time and explained to Mrs U.
51. Based on the information Mrs U has provided us with, it is clear she was aware her stitches needed to be removed and that she needed to keep the area dry. This is evidence of advice being given. We are sorry to hear she believes this information was insufficient but because we can see this was in accordance with the guidance above, we cannot say the Trust has done anything wrong.
Discharge summary
52. Mrs U is concerned the Trust did not inform her GP Practice of her injury. She confirms her Practice did not receive anything from the Trust despite receiving communication from Hospital A.
53. The Trust has explained in its final response that it did send a discharge summary to the GP Practice electronically on 27 February.
54. Our adviser explains this is good practice but not essential and notes there is evidence in the records to show this has been done.
55. Our adviser says informing the patient’s GP Practice is not essential because when a patient needs to arrange to see their GP to have their stitches removed, they should raise any concerns about pain at that time and this will be addressed by the Practice.
56. Overall, we cannot hold the Trust accountable for the GP Practice not receiving the discharge summary as it is impossible to find out why the Practice did not receive it. We have seen evidence this was sent.
57. Based on this we cannot say the Trust has done anything wrong and will not consider this part of the complaint further.