23. The medical records do not mention the decision to order an MRI scan of the knee instead of the calf. The only information on this is in the Trust’s complaint response letters, dated 27 April and 9 June 2021, to Mr A. It said the first request for an ultrasound of the calf was rejected and a radiologist requested this was changed to an MRI scan. The radiologist thought an MRI scan would be better to identify the injury. It said the error occurred when the emergency department consultant who reviewed this requested an MRI scan, but only of the knee. The Trust has accepted this was an error.
24. GMC good medical practice 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’.
25. The Patient.info article says ultrasound or MRI may be necessary if the diagnosis is unclear. An MRI scan should also be used to decide if there is achilles tendon damage or partial thickness tears.
26. Our decision is the correct request was made by the emergency department consultant for an ultrasound scan of the calf. This was made in line with the above guidance. Our emergency medicine adviser said that ultrasound scan of the calf is not an investigation that is done in the emergency department. The normal procedure is for a patient to be referred as an outpatient for a scan, to be done by a radiologist or ultrasonographer.
27. Both our emergency medicine and orthopaedic adviser said not requesting the correct scan of Mr A’s leg, led to a failure to diagnose him. This meant Mr A was not referred to an orthopaedic surgeon when he should have been. Our orthopaedic adviser said the error led to a delayed diagnosis of an Achilles tendon tear.
28. We do not know why the Trust did not ask for a scan for the right body part. We can only assume this was due to human error when the request was changed from ultrasound to MRI. The MRI scan should have been of Mr A’s calf and not his knee. We have decided that changing the body part to be scanned was a failing.
Impact
29. Mr A said he was told during his consultation that it is now too late to have surgery. This was due to the delay in diagnosis and the healing which had already taken place. Mr A says a lot of time, financial cost and stress has been wasted. This had an impact on his wellbeing, physical, mentally, and emotionally.
30. When considering how Mr A was affected, we looked at what actions the Trust has taken to put this right. We can see the Trust has apologised for the mistake. It explained that the emergency department consultant was responsible for this error and it accepted this caused undue distress and discomfort. It said the experience has been shared with individuals involved in the care and the wider team for reflection and future learning.
31. Unfortunately, cannot answer why ‘calf’ was changed to ‘knee’ on the MRI scan request. We have not seen any evidence in the medical records to confirm if the emergency department consultant made the mistake, but we are content with the explanation provided by the Trust.
32. We are pleased to see the Trust accept this error and have recognised the distress and discomfort this caused Mr A. The Trust planned to reflect on the error and share this complaint for future learning. We have not seen any evidence this has been completed and there are outcomes Mr A is looking for that have not been considered.
33. We know the results of the later scan of the calf. The National Library of Medicine and BOFAS guidance explains how to treat this condition. They both say the best outcomes are achieved through surgical reconstruction.
34. During consultations on 14 October and 4 November 2020, both private consultants commented on the length of time which had passed since the injury and the impact this had on Mr A. It was noted that the tendon tear was already ten weeks old. It had already started to heal, with scarring and a degree of lengthening, which has caused weakness and an inability for Mr A to walk on his tip toes. It was recorded he was left with a noticeable functional deficit. The consultant who saw Mr A on 4 November 2020, also advised against surgery due to the duration of time. Based upon this advice, we know Mr A would have been considered for surgery sooner.
35. We have decided that this is a direct result of the incorrect scan being carried out on 18 August 2020. This has led to an impact on Mr A’s physical health. We know from the consultants he saw on 14 October and 4 November 2020 that he now has a weakness in his achilles tendon. We appreciate this has been extremely frustrating and caused stress and upset.
36. Mr A had to arrange his own appointment with a private consultant, which led to an MRI scan and diagnosis of his achilles tendon tear. Mr A paid £460 for this consultation. Mr A tried to obtain a scan and diagnosis through the NHS, but the incorrect scan was carried out on 18 August 2020. Following this, on 28 August 2020, Mr A’s GP made a referral to musculoskeletal services via the NHS. As Mr A was very active, and there were ongoing delays due to COVID pressure, his GP suggested arranging a private appointment.
37. Mr A attended a private appointment in September 2020. Following an assessment, a physiotherapist made an onward private referral for a consultant who specialises in the management of patients with Mr A’s symptoms. This led to the correct scan and diagnosis.
38. In our view, Mr A tried to obtain his treatment via the NHS. If he had waited for an NHS appointment this would have prolonged his waiting time for a diagnosis and treatment. Mr A was an active person who had already waited several months because an incorrect scan was taken of his knee instead of his calf.
39. Mr A’s symptoms were worsening at the time. We know from the comments made by the private consultants on 14 October and 4 November 2020 that the delayed timeframe had impacted his healing process. Because of this, we have decided that Mr A’s financial loss is a direct result of the failings we have identified. This is because there was a missed opportunity to treat Mr A earlier. We also find that the failings led to additional stress and time taken for Mr A to arrange his own medical appointments privately.
40. We have seen no evidence that the Trust has considered the financial impact caused to Mr A. We have seen receipts totalling £460, which was spent on arranging private consultations. Mr A was also aware of the incorrect scan when arranging his private appointment. There is a receipt for £50 for physiotherapy, one for 200 for a consultant at a private hospital, and another for £210 for a consultant at a different private hospital.
41. It is not possible to put Mr A back into the position he would have been in, had there not been any failings. This is because there was a missed opportunity to treat him earlier. We think an apology does not go far enough to put this right. We have therefore considered a financial remedy in recognition of this.
42. We have asked Mr A for an updated position on his symptoms. Following his MRI scan, Mr A had a few sessions of physiotherapy. He said he would describe his left calf as being six out of ten (with ten being normal). He has difficulties in pushing off with his left foot and in using the clutch pedal when driving.
43. This confirms the advice Mr A was given during consultations on 22 September, 14 October and 4 November 2020. The tendon had already started to heal, with scarring and a degree of lengthening, which had caused some weakness and an inability for Mr A to walk on his tip toes.
44. Mr A had a noticeable functional deficit and significant weakness on his left side. He would likely continue to not be able to walk on his tip toes. Our orthopaedic adviser said the inappropriate treatment of the Achilles tendon tear led to the tendon healing in a lengthened position and caused associated weakness. It is our view the evidence and advice from our adviser suggests the symptoms Mr A complains about are permanent. We have decided the failings we have identified led to the ongoing weakness.
45. We also appreciate that the events have been stressful and upsetting for Mr A. He has had to use his own time to arrange private consultations and engage in unnecessary communication with the Trust. If the correct scan had been undertaken Mr A would not have needed to complain or arrange private treatment.
46. In determining an appropriate amount to recommend, we use our Scale of Severity of Injustice scale, which allows us to make sure the recommendations we make are consistent and transparent for everyone. Our scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of financial amounts we would usually recommend in those circumstance.
47. In our view this complaint falls within the middle range of a level three injustice. The failings we have found have caused a moderate impact to Mr A, impacting his physical and mental wellbeing over a significant period of time. Mr A has been left with a weakness on his left side and cannot walk on his tip toes.
48. The evidence suggests this is likely to be the scenario going forwards, and the failings we have identified were what caused the associated weakness. Our consideration also takes into account the time Mr A has taken to arrange private consultations via his GP and engage in unnecessary communication with the Trust following their mistake. This would not have needed to happen if the correct scan had been done.