Safeguarding referral
16. Before we decide if we should do 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 seen any signs that the Trust was wrong to make a safeguarding referral.
17. Before we go on to explain our decision in more detail, we want to acknowledge how upsetting the Trust’s actions were for Ms O. We do not underestimate this. Our decision is not meant to devalue Ms O’s experience in anyway.
18. Ms O says the safeguarding referral was based on lies and racial discrimination. The Trust said the referral was made ‘as an offer of support’ in the community for after discharge, to allow liaison between the GP and other services. It is clear from the hospital records and Ms O’s own account that the ED team discussed a referral with her and she did not agree.
19. We have considered if the Trust acted appropriately in making a safeguarding referral and what should have happened in view of Ms O’s disagreement with a referral.
20. The Trust’s safeguarding policy mirrors guidance from the GMC. The GMC accepts this is a difficult area and can mean the doctor must go against the wishes of patents. The guidance is clear that the interests of the child(ren) must come first.
21. Our adviser explained that because the potential consequences of not referring are so high, doctors are encouraged to over-report to reduce the risk of missing something. It is a judgement call, based on the information available there and then, and is subjective.
22. In this instance, the paramedics raised concerns to the medical team. Our adviser said the doctors had a duty to take the paramedics’ concerns one step further. The doctor documented enough concerns/triggers to justify the referral and the referral was made in the context of providing support. Given this, we see nothing to say the referral should not have been made. It could be argued the doctors would have been negligent if they had not made a safeguarding referral.
23. It should be remembered that the purpose of a referral is to establish if a child is at risk or needs extra support. It is not an assumption that the parent has done anything wrong.
24. In relation to Ms O’s concern that the doctors made the referral without her permission, the Trust’s safeguarding policy says parents should normally be made aware of and/or consent to the sharing of information. But, it also states ‘it is not necessary to seek consent to share information for the purposes of safeguarding and promoting the welfare of a child…’
25. The GMC guidance, section 11 states:
‘If, having discussed the issues with the parents, you still have concerns that a child or young person is at risk of, or is suffering, abuse or neglect, whatever the cause, you must tell an appropriate agency…’
26. The GMC encourages working in partnership with families, but, this is not to be at the potential cost to a child. Given this, we have seen no signs that the Trust was wrong to decide to go ahead with a referral when Ms O disagreed.
Rib injury
27. Ms O says the ED team failed to properly investigate the cause of her chest pain so missed that she had a fractured rib. She explained how she would have been careful if she had known about the fracture, rather than carrying on as normal.
28. Information for patients and GPs on the Patient.info website explains diagnosis of rib injuries is usually based on clinical signs (the patient’s symptoms, the history of the problem and the doctor’s examination).
29. Our adviser explained X-rays are not done routinely when a broken or bruised rib is suspected. This is because new fractures cannot always be seen on X-ray and because of the risks associated with exposure to radiation, that outweigh any benefit from a confirmed diagnosis. Confirmation of a broken rib would not change how the patient’s condition was managed because there is no treatment for a broken rib.
30. The only time an X-ray would be done is if there was evidence of any internal damage, for example bleeding or a punctured lung. Our adviser confirmed Ms O had no signs of internal injury.
31. The doctor who examined Ms O noted she had a ‘mildly tender chest wall’, ‘epigastric tenderness’ (pain or discomfort in the upper abdomen, below the ribs) and that her chest was clear. They also did an ECG (a test that records the electrical activity of the heart) which was normal, and this addressed any concern about a heart-related cause for the symptoms.
32. The focus of the examination seems to have been on Ms O’s hip symptoms and the safeguarding concerns. Although in these circumstances it is understandable why the doctor was not focused on the possibility of a rib injury, our adviser said they should have considered the possibility and explained this to Ms O.
33. There is no specific guidance on what patients should be told about a possible rib injury. RCEM best practice guidance says patients should be given information on discharge that includes advice on pain relief, injury or illness-specific information and advice about the symptoms that should prompt further assessment. Our adviser said normal advice on rib injury is to take things easy for a while, that it can take up to six weeks to heal and to take regular pain killers. It does not seem the Trust gave Ms O any advice about this.
34. We have considered what difference this might have made to Ms O. She says the failure to give any advice meant she was not aware of the need to rest, potentially prolonging her pain. She says it also meant she had no peace of mind about the cause of her pain. We agree that having knowledge of a possible rib injury would have been beneficial to Ms O.
35. In summary, we are satisfied there was no reason for the Trust to do a chest X-ray at the time and that the ED team appropriately examined Ms O to rule out a cardiac cause for the pain. But, we think the doctors should have considered the possibility of a rib injury, explained this to Ms O and given appropriate advice. There is no evidence this happened. We can see a potential link between this and the impact Ms O told us about. The Trust did not acknowledge this issue before we raised it.
36. Ms O told us she wants the Trust to acknowledge its failings and to apologise for the impact these had on her. She also wants to be reassured that the Trust has learned from her experience so other patients do not go through the same.
37. We shared what we have seen with the Trust and asked it to write to Ms O to:
• acknowledge it should have considered the possibility she had a rib injury, explained this to her and given her advice on how to manage this • apologise that not doing this meant she did not know to rest, which may have prolonged her pain, and she did not have an explanation for the cause of the pain • explain what action it will take to learn from her experience.
38. The Trust has agreed to do this and said it will aim to write to Ms O by mid-March 2024. We consider this, along with the explanations we have included in this statement, a good resolution to the complaint.
39. We hope this will reassure Ms O that her concerns have been taken seriously. We thank her for bringing this matter to our attention.