Did not conduct an arthroscopy of her right knee
14. 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 seen any signs that something has gone wrong.
15. The Trust reviewed Ms A in November 2020 after her fall. It took an X-ray which showed no obvious bony injury. Ms A however was in significant pain and had difficulty walking properly. The Trust referred Ms A for a period of physiotherapy which was unsuccessful.
16. After this the Trust arranged for Ms A to have a magnetic resonance imagining scan (MRI) on 2 March 2021. The Trust said the result showed no injury that could be treated by a surgical procedure. Ms A was being treated with codeine (a painkiller) and physiotherapy continued.
17. A doctor examined Ms A at an appointment at the Trust on 16 June 2021. The doctor observed Ms A to be walking unevenly and using a stick which was partially weight bearing. The doctor assessed Ms A’s knee and said there was no obvious visible problem with its position in general. The doctor felt Ms A’s knee and said she had altered sensation over the knee area. The doctor indicated a reasonable range of movement in her ankle, observed no swelling on the knee but said it had some limitation in movement, and the knee was globally tender. The doctor said the MRI scan was normal.
18. NICE CKS ‘How do I exclude fracture using the Ottawa knee rule?’ says the rule is used to decide whether an X-ray is needed in people with suspected knee fractures to exclude a fracture, one indication being an inability to weight bear. The Trust did an X ray after Ms A’s fall in November 2020 which showed no bony injury. The Trust also did an MRI scan of Ms A’s knee.
19. NICE CKS ‘How should I examine a person with knee pain?’ says the doctor should examine and compare both knees and surrounding structures, inspect, examine by touch, move the knees, examine hips, ankles and spine, assess gait and ability to weight bear, and assess for signs of septic arthritis. The doctor’s assessment of 16 June 2021 was in line with this.
20. But, Ms A believes the Trust should also have done an arthroscopy.
21. The GMC standards say:
‘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 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 where this serves the patient’s needs’.
22. There are no other specific guidelines around when an arthroscopy should be done. Our adviser confirmed Ms A had appropriate examination and investigations of her knee problem in line with the NICE standards above. They said the MRI scan did not reveal issues with the knee. They said a knee arthroscopy would not be needed when no specific knee problems had been found. We also note Ms A was referred on for a second opinion from a specialist knee surgeon.
23. We have seen no signs the Trust acted outside of GMC guidance by not doing suitable investigations. In this case, suitable investigations did not include a requirement for the Trust to do an arthroscopy as the MRI scan did not find any issues.
24. As we have seen no signs that something has gone wrong, we will not take any further action.
Advice to use a mirror to check her knees
25. Ms A said at her appointment of 16 June 2021 she was upset by comments the doctor made. She said the doctor told her they thought the pain was in her head and suggested she put a mirror between her legs and look at the reflection of her knees to make sure herself there was no swelling to the injured knee.
26. The Trust responded on 26 July 2021 after speaking with the doctor involved. The doctor remembered the discussion he had with Ms A, explaining the possible diagnosis of CRPS and what that meant. The doctor explained CRPS is a condition which may involve problems with nerves in a limb after any injury, which may send nerves to a person’s brain that are not processed as they would normally be. The doctor apologised for the upset and offence caused and said he did not mean to suggest it was in Ms A’s head. The doctor explained using a mirror to look at the knees was a technique used by physiotherapists. The doctor apologised for any offence caused.
27. Mirror therapy aims to change the way someone’s brain thinks by carrying out movements and activities with the unaffected limb in the mirror. This is to reduce painful signals the brain receives from the painful limb. Watching the unaffected limb reflected in the mirror can stimulate both sides of the brain and correct painful representations of the affected limb that develop when an injury or loss of limb happens.
28. The NHS website lists this as a technique that can be used by patients who have CRPS. It says mirror therapy can improve movements by retraining the brain for missing or confused bits of information.
29. We understand Ms A was upset with the doctor’s comments about the mirror. We are satisfied that suggesting the use of a mirror is an accepted technique in injuries like Ms A had. We have therefore seen no signs the Trust acted outside of relevant standards in giving its advice. We are not taking any further action on this issue.
30. We appreciate Ms A has experienced pain for a long time since her knee injury and we were sorry to hear how this has affected her.