Investigating shoulder injury
22. Before we decide if we should conduct a detailed investigation of 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 have not found any indications that something has gone wrong.
23. Miss A says between 16 and 20 October, the Trust did not investigate her shoulder pain or how distorted her shoulder looked, following a fall at home.
24. The Trust said staff performed a full primary and secondary surgery survey, according to ATLS guidelines, and carried out CT scans of the head, chest, abdomen, and pelvis.
25. It also said Miss A was seen daily during the major trauma ward round and there is no documentation that she mentioned shoulder pain during any of the team’s reviews.
26. We have considered Miss A’s care and treatment in A&E, and when she transferred to the major trauma team as an inpatient.
A&E
27. Miss A’s medical records show she arrived in A&E by ambulance, and the ambulance service recorded she had been drinking alcohol, had fallen down 15 stairs, and had sustained injuries to her head. The ambulance service gave her a GCS (Glasgow Coma Score) of 14. A score of 14 shows she was confused.
28. We can see from the records staff in A&E carried out a primary survey of Miss A which included requesting and carrying out a trauma CT scan. This scan surveys the body from the top of a patient’s head to the bottom of the pelvis.
29. The records document that the trauma CT scan revealed fractures to Miss A’s second, third and fourth ribs on the left-hand side.
30. It is also recorded staff in A&E completed a secondary survey assessment. During this assessment, a doctor noted NAD (no abnormality detected) when assessing Miss A’s arms.
31. The relevant guidance for the part of the complaint where Miss A was the responsibility of A&E, is ACS.
32. To help reach a view on this complaint we sought the advice of our A&E adviser.
33. Miss A was taken by ambulance to a major trauma centre. This is different to a ‘normal’ A&E department as each centre is equipped to deal with patients who have had major trauma.
34. Our A&E adviser explained that by taking Miss A there the ambulance service was concerned she had suffered potential life-threatening injuries and the primary aim of the centre would have been to identify and treat any life-threatening injuries as quickly as possible.
35. We can see the Trust acted in line with the guidance because it carried out an initial and immediate primary survey including a trauma CT scan and blood tests, given Miss A had presented with evidence of head injuries resulting from falling down 15 steps.
36. The primary survey did not reveal any life-threatening injuries that required immediate life-saving treatment (such as internal bleeding), but it did identify fractures to three of Miss A’s ribs which would need further assessment.
37. We are satisfied examining the acromioclavicular joint (the joint on top of the shoulder) should not have formed part of the primary survey and staff should not have identified the injury here. We also note the Trust’s response of 17 February in which it explained that during the trauma CT scan, Miss A’s hands were placed above her head and was the reason the scan would not have inadvertently picked up the acromioclavicular joint injury.
38. Our A&E adviser said it was reasonable for staff to carry out the scan in this way as the focus of the scan is to identify internal injuries to the head or body requiring immediate life-saving treatment.
39. We can also see staff in A&E undertook a secondary survey after the primary survey. Our adviser explained this assessment is designed to try to identify any other less serious injuries and involves staff examining every part of the patient’s body.
40. It is evidenced in the records that a doctor assessed Miss A’s arms and did not identify any injuries.
41. We are, therefore, satisfied staff carried out an appropriate secondary survey assessment to include Miss A’s arms. This was in line with the guidance.
42. We fully appreciate Miss A has a different perception of what happened.
43. There are several possible reasons why the acromioclavicular joint injury might not have been discovered during the appropriate secondary survey.
44. Our A&E adviser explained that Miss A’s shoulder pain might have been masked by:
· a distracting injury such as her rib fractures which are very painful
· the ambulance service giving her intravenous paracetamol (a pain killer)
· her having alcohol before her injuries.
45. We can also see Miss A had sustained an injury to her head which was significant enough to have knocked her out for ten minutes and render her confused, initially. Our A&E adviser also explained that despite her GCS score having risen to 15 (normal) in A&E, the after effects of her head injury may have contributed to her not being aware of the injury to her shoulder at the time of the secondary survey.
46. Based on all the available evidence, including our advice and relevant standards and guidelines, we are satisfied staff in A&E did what they should have to assess and investigate Miss A’s shoulder injury.
Major trauma team
47. After she left A&E, Miss A’s medical records do not document any concerns from staff about her shoulder or record complaints she herself raised.
48. Miss A’s records do include notes about her care in relation to her laceration injuries, which a plastic surgeon treated and her nose injury which the ear, nose and throat team treated.
49. We have also seen that general surgery was involved in her care in relation to her chest injuries.
50. To help us reach a view in relation to this part of Miss A’s complaint we sought the advice of our orthopaedic adviser.
51. They explained that rib fractures, such as those suffered by Miss A, are usually treated by other clinicians such as general surgeons and not orthopaedic staff.
52. An injury to the acromioclavicular joint would require orthopaedic involvement. Our adviser further explained there is no evidence of an orthopaedic injury that needed the orthopaedic team to get involved.
53. We cannot say the Trust did anything wrong here and should have done any more in relation to Miss A’s shoulder injury. This is because the records do not indicate that there were any symptoms or concerns of a shoulder injury that staff in the major trauma team needed to assess and investigate further.
54. Once again, we fully respect Miss A tells us that she told staff about her shoulder pain and she thinks the joint was distorted. We are sorry that we are unable to provide any further information for her in relation to her shoulder injury after she left A&E and was discharged home on 20 October.
55. We will not take any further action in relation to this complaint issue on the basis we have not seen any indication anything went wrong.
X-ray on 19 October
56. Miss A says the Trust did not diagnose a dislocated shoulder from an X-ray it carried out on 19 October even though in it later accepted there was evidence of the dislocation on the X-ray.
57. The Trust said the major trauma team arranged a chest X-ray on 19 October to follow up Miss A’s chest CT scan.
58. The Trust also confirmed the dislocation could be identified on Miss A’s chest X-ray but explained, without the benefit of hindsight, it would have been very difficult to identify. The Trust said the main reason for the X-ray was to assess Miss A’s chest for a possible collapsed lung.
59. To help reach a view in relation to this complaint we sought the advice of our orthopaedic adviser.
60. Our orthopaedic adviser explained with the hindsight of knowing there was a shoulder injury at the time of the X-ray it is easy to look at the image and notice the injury. A chest X-ray is not ideal, however, to look for shoulder injuries.
61. They also said there is no relevant clinical guidance in relation to this complaint but, based on their clinical experience, when an X ray is requested to look at particular part of the body, it is understandable staff would only look at the relevant parts.
62. Our Principles of Good Administration state organisations must act in accordance with recognised quality standards, established good practice or both when delivering clinical care. In this situation, we are satisfied the Trust followed established good practice given there are no recognised quality standards.
63. Based on all the available evidence including our clinical advice and our Principles, we do not think there are indications the Trust did anything wrong in not diagnosing Miss A’s shoulder injury when staff took the X-ray on 19 October. The attention of the clinicians looking at the image would have been on the chest area and not on the shoulder. They also did not have the benefit of hindsight when viewing the image.
64. We will not take any further action in relation to this complaint.
Complaint response
65. Miss A says she is unhappy with the Trust’s complaint response which explained it did not identify the dislocation on the X-ray (of 19 October) because it was looking for fractured ribs.
66. In its written response of 15 April, the Trust said with the benefit of hindsight Miss A’s chest X-ray (of 19 October) shows an acromioclavicular joint dislocation. It explained because the X-ray was taken in order to assess her rib fractures, and was not looking for a shoulder injury, it was entirely understandable that the dislocation was not spotted at the time.
67. Our Principles Of Good Complaint Handling state that organisations should ‘provide honest, evidence based explanations and give reasons for decisions’.
68. Based on our work looking into Miss A’s complaint about the X-ray on 19 October, we think the Trust has provided a complaint response in line with our Principles.
69. This is because we have not seen indications the Trust did anything wrong in not diagnosing Miss A’s shoulder injury when staff took the X-ray on 19 October. We are satisfied the attention of the clinicians looking at the X-ray image would have been on the chest area and not on the shoulder. The Trust’s written response matches what we have seen.
70. We will take no further action in relation to this complaint issue.