University Hospitals Birmingham NHS Foundation Trust

4. Mrs K had a fall on 28 March 2021, which caused two fractures to her wrist. She complains about the treatment she received from the Trust after this, saying:

• the conservative (non-surgical) treatment was not good enough, the Trust took the cast off too soon and the telephone physiotherapy was of no use. She says the Trust wrongly noted the details of her fall despite her explaining many times what happened

• she saw four different doctors and it was only after she complained that she got an appointment with a wrist specialist.

5. Mrs K says because of this she experienced misalignment of her wrist (her wrist was not in the right position), ongoing severe pain and discomfort and restricted wrist and hand movement. She says the wrong details of the fall being noted affected her treatment options. She says physiotherapy only increased her pain. She says the care she received made her feel frustrated and that she was not listened to. She explains she cannot do daily tasks without pain and discomfort and often needs her husband’s help. She says she needs two corrective surgeries and is waiting for these. She says she continues to wear a splint and not being able to use her hand is making her feel anxious, depressed, and worried about the potential outcome of the surgeries she needs.

6. Mrs K wants the Trust to make service improvements and financial compensation.

7. Mrs K was in her seventies when she fell on 28 March 2021. She attended A&E and had her right wrist X-rayed. She was given a back slab (a partial cast commonly used as a first-line treatment when a fracture is swelling).

8. Mrs K went to a fracture clinic on 30 March. The X-ray results show Mrs K had a wrist fracture. A wrist fracture is a break in the radius bone (one of the long bones in the forearm) close to the wrist. We can also see that a piece of her ulna styloid (wrist end of ulna bone, the second of the long bones in the forearm) got pulled away from the main part of the bone.

9. The examination on 30 March showed Mrs K had active finger movements and intact sensation. The doctor told Mrs K how to mobilise (move and exercise) her fingers, elbow and shoulder to avoid stiffness. The plan was to see her in a week for a cast change.

10. Mrs K went to a fracture clinic on 6 April and a cast was fitted. The plan was to remove the cast in four weeks and begin mobilisation. On 4 May, a doctor removed her cast and put her in a splint (a device supporting and stopping the injured part of the body from moving) for ten days. They referred her for physiotherapy (which started on 17 May) and discharged her from the fracture clinic.

11. Mrs K went to A&E on 6 June due to the pain she was experiencing in her wrist which she said ‘never healed’. The examination showed she had a deformed wrist. Mrs K had an X-ray and a doctor arranged for a follow up at a fracture clinic. The Trust gave her a splint.

12. Mrs K went to a fracture clinic on 15 June and an examination and X-ray showed her wrist was deformed. A doctor referred her for a CT scan and advised her to remove the splint and move as much as the pain would allow.

13. Mrs K went to a fracture clinic on 15 July. A doctor explained to Mrs K that her CT scan showed a loss of bone mineral density (the amount of mineral in the bones) that weakens bones). The records say Mrs K wanted surgery to realign her bones. The doctor referred her to a consultant hand surgeon on 28 July.

14. Mrs K went to an appointment with the consultant hand surgeon on 13 October. They recognised she needed surgery but asked her to stop smoking before she was put on the waiting list.

15. Mrs K was added to the waiting list on 23 March 2022 after a follow up appointment with the consultant hand surgeon. Mrs K had a CT scan on 4 August which confirmed the previous findings. We note she was still waiting for surgery at that point.

19. Mrs K says the Trust’s conservative treatment was not good enough. She says the Trust took the cast off too soon and the telephone physiotherapy was of no use. The Trust explains its conservative treatment was in line with the BOAST standards.

20. The BOAST standards say for patients over the age of 65, conservative treatment is preferred for wrist fractures where a bone fragment is bending towards the back of the hand. This is unless there is a significant deformity or neurological compromise (problems with how the brain receives and sends information in the body area).

21. The BSSH guidance says it found that for patients over 65, manipulation (a non-surgical treatment) may not improve the clinical outcome compared to no manipulation. This is in terms of mobility of the wrist, its stiffness, final position of the bone and physical appearance of the wrist.

22. We can see Mrs K initially had conservative treatment to treat her wrist fracture. The Trust referred her to a consultant hand surgeon on 28 July, about four months after she had the injury.

23. Our adviser explained the conservative treatment was in line with the guidance.

24. Mrs K’s age and the type of fracture she had meant conservative treatment was recommended, in line with the BOAST standards and the BSSH guidance. There was no neurological compromise either. The notes from 30 March 2021 confirm a doctor examined Mrs K and she had sensation in her wrist and hand.

25. As the Trust’s decision to give Mrs K conservative treatment was in line with the relevant guidance, we have not found evidence of a failing.

26. We will now look at whether the Trust removed Mrs K’s cast at the right time.

27. Mrs K had a partial cast for almost a week from 28 March until 6 April. On 6 April, she was fitted with a full cast which she had for about four weeks, until getting a splint.

28. The BOAST standards say a doctor should ‘consider removing the cast and starting mobilisation four weeks after injury’.

29. Our adviser explained common practice is to immobilise wrist fractures for as short a time as possible.

30. We consider the Trust removed Mrs K’s cast in line with the BOAST standards. This is because she had a cast on for five weeks, including the partial cast. We have seen no evidence of a failing with this treatment.

31. Mrs K told us the telephone physiotherapy was of no use. The Trust said not all patients need physiotherapy and face-to-face is reserved to those who fail to make progress.

32. We can see Mrs K had telephone physiotherapy on 17 May, 8 June, 22 June, 27 July, and 10 August. She missed one telephone appointment on 1 June. She also had appointments on 6 July, 21 September, 8 October, and 29 October which were face-to-face. Mrs K was discharged from physiotherapy on 29 October.

33. The GMC guidance says a doctor must ‘provide effective treatments based on the best available evidence’. The HCPC standards say physiotherapists must ‘be able to make reasoned decisions to initiate, continue, modify or cease techniques or procedures’.

34. We asked our adviser whether Mrs K should have been referred for face-to-face physiotherapy. They told us that telephone physiotherapy is a good balance between a patient’s expectations and using resources efficiently.

35. We recognise the NHS brought in telephone appointments because of COVID-19. In its letter to Mrs K dated 7 May, the Trust explained it wanted to limit footfall across its sites to limit patients’ exposure to the virus.

36. We consider that starting Mrs K with telephone physiotherapy was in line with the GMC and HCPC standards. We can see the Trust changed to face-to-face appointments when Mrs K made no progress with her recovery. We have seen no evidence of failing as the Trust followed the guidance. We do not uphold this part of complaint.

37. Mrs K says the Trust wrongly noted the details of her fall despite explaining what happened many times. The Trust said how the injury happened would not have changed the treatment.

38. Mrs K says the records say she fell ‘forward and put her hand out in front to save herself’ which is not correct. She says she ‘fell on her left side and slammed the back of her hand on the very hard floor’.

39. We note the records detail Mrs K’s fall as ‘fell over onto hand’ and ‘right hand under her when she fell’. We note the Trust’s complaint response says she ‘sustained a fall onto her outstretched hand’.

40. We can see there is a difference between what is noted in the records and what Mrs K says. We have no reason to doubt Mrs K’s recollection of her fall.

41. The BOAST standards say the mechanism of injury (how it happened) and clinical findings should be documented at presentation (when the patient is reviewed).

42. We asked our adviser whether how Mrs K fell could have affected her treatment options. They told us this would not have made a difference. They explained this is because the development and characteristics of the injury are shown by the X-ray. They said any decision on treatment would have been based on the X-ray, examination and consideration of the patient’s general health and other health issues.

43. The Trust has not recorded the details of Mrs K’s injury in line with the BOAST standards. But, we do not think this affected Mrs K’s treatment options. This is because how Mrs K injured her wrist would not be the deciding factor on the treatment she would have. We hope Mrs K finds it reassuring that this had no clinical impact.

44. We understand Mrs K would have found it frustrating and felt ignored. When someone has been affected in this way but there was no clinical impact, we would normally recommend that the Trust apologises. In line with our guidance on financial remedy, we do not think the impact is enough for us to recommend any financial compensation.

45. Mrs K did not tell us she wanted an apology so we have not recommended for the Trust to do this. We partly uphold this part of complaint.

46. Mrs K told us she saw four different doctors and it was only after she complained that she got an appointment with a wrist specialist. The Trust explained wrist fractures are common and can be dealt with by the fracture clinic.

47. The GMC guidance says a doctor must ‘share all relevant information with colleagues involved in the care, including when they are off duty or referring a patient’. It also says a doctor must ‘refer a patient to another practitioner when this serves the patient’s needs’.

48. We can see Mrs K saw a different doctor each time she attended the fracture clinic between 30 March and 15 July.

49. The records show that on 30 March 2021, Mrs K’s first appointment at the fracture clinic, the specialist doctor discussed her care with a consultant. Our adviser saw no issues with the management decisions made at the appointments. They told us these were consistent with the plan made on 30 March.

50. We recognise it is normal practice for a fracture clinic to be staffed by different members of the team. This is because of the complex shift and rota patterns needed to staff a large department. This means a patient may not see the same doctor each time.

51. We have not seen any evidence to suggest the Trust did not follow GMC guidance to share all the relevant information with colleagues. This is because we can see there was continuity of care and the plan made on 30 March was followed.

52. We asked our adviser whether the referral to the consultant hand surgeon was in line with the GMC guidance. They explained a lot of symptoms will settle over time. They said doing an assessment sometime after the injury and when initial treatment has been given, gives a clearer picture of what long term symptoms may need to be addressed.

53. After Mrs K returned to the A&E on 6 June, the Trust ordered another X ray and arranged a follow up at the fracture clinic. The fracture clinic reviewed Mrs K on 15 June and ordered a CT scan. The Trust saw her again on 15 July when it made a referral to the consultant hand surgeon.

54. We consider the Trust acted in line with the GMC guidance. This is because once it became clear that Mrs K’s fracture was not recovering and her wrist was deformed, the Trust arranged appropriate investigations and made a referral shortly after.

55. We recognise the timing of this crossed with the time Mrs K complained about the care she was getting. We think the Trust made a referral at the right time based on Mrs K’s ongoing symptoms in line with the relevant guidance. We do not uphold this part of the complaint.

1. The Parliamentary and Health Service Ombudsman are sorry to learn of Mrs K’s concerns, how she says her treatment options have been affected and how she worries she lost an opportunity for a better clinical outcome. We hope our findings give some reassurance about this. We are pleased to hear she has now had successful surgery on her wrist.

2. We have carefully considered Mrs K’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We have seen no failings in the Trust’s management of Mrs K’s treatment, when it took off her cast or with the telephone physiotherapy it gave. We have also seen no failings in how many different doctors Mrs K saw and when she got an appointment with the wrist specialist. We do not uphold these parts of complaint.

3. We have seen some failings in the Trust wrongly noting the details of Mrs K’s fall. We consider this had no clinical impact, but we recognise it would have caused Mrs K frustration and to feel that she was not being listened to. Usually, we would recommend an apology for a failing like this that has had an emotional impact on Mrs K. Mrs K did not tell us she would like an apology, so we have not recommended this. We partly uphold this part of the complaint.