Checking the fitting of the hinged brace
14. Mrs A complains a consultant should have checked the fitting of her hinged brace on 4 November 2022 before she left the fracture clinic to go home.
15. Mrs A says a consultant took her down to the plaster room but they never checked the hinged brace and instead only the technician did this.
16. In the Trust’s complaint response it said it is always difficult to change from plaster support to a hinged brace when attempting early mobilisation (movement) when there has been a significant fracture. It explained that because of this, the ongoing discomfort Mrs A experienced was not due to an oversight by the doctor but was one of the possible outcomes of her injury. It apologised for the discomfort caused to her.
17. GMC guidance says:
‘15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• 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 • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’
18. The records show Mrs A attended the outpatient clinic on 4 November 2022, where the registrar noted they removed her back slab and her bruising was settling down. They noted they had supported her with a hinged elbow brace locked at 90 degrees. The plaster room request form shows the plaster room technician got verbal consent for treatment, explained verbal instructions, fitted the elbow brace and noted the patient was comfortable.
19. We asked our adviser to help us understand who should have applied and checked Mrs A’s hinged brace.
20. Our adviser explained usually it would be a plaster technician who would apply the hinged brace in the plaster room, get verbal consent and give relevant instructions and this process was followed.
21. Our adviser said a hinged brace is not routinely checked by a doctor when there are no concerns from either the plaster technician or the patient. Based on the available records, it does not seem there were any concerns about the brace at the time.
22. Having considered the available evidence, we think the Trust acted in line with GMC guidance. The consultant (doctor) referred Mrs A to the plaster room technician and there is nothing to suggest this was not appropriate in her circumstances. We appreciate Mrs A’s view that a consultant should have checked her brace. Based on the evidence, we cannot say this was needed. As we have not seen any signs to suggest anything went wrong, we do not need to take any further action.
Delay removing the hinged brace
23. Mrs A complains the Trust should have removed her hinged brace and replaced this with a soft cast before she left A&E on 7 November 2022, rather than leaving her another five to six hours until her appointment at the fracture clinic at 10.30am that day.
24. In the Trust’s complaint response it said the doctor in A&E referred her to the orthopaedic team and the on call orthopaedic junior doctor reviewed her and discussed her case with the more senior on call orthopaedic doctor. They felt they could discharge her and follow up with her in the fracture clinic. The Trust said it appreciated Mrs A’s frustration about this, as she was worried about her case, but the orthopaedic team felt this was the most appropriate treatment plan for her.
25. It also said the on call orthopaedic doctor decided the most appropriate place to address her concerns with her cast fitting was the fracture clinic and this is why it discharged her and asked her to attend the fracture clinic later that morning. It explained the emergency department covers a wide range of treatments and conditions but if they can use the specialist services and improve outcomes for patients, they will usually refer to the specialist area.
26. The GMC guidance says:
‘14 You must recognise and work within the limits of your competence.’
‘16 In providing clinical care you must:
• prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence • take all possible steps to alleviate pain and distress whether or not a cure may be possible • consult colleagues where appropriate’.
27. The records show Mrs A attended A&E on the evening of 6 November and the A&E team and orthopaedic team reviewed her. The notes say she reported pain and swelling of her left hand and she said her pain was managed with naproxen and paracetamol at first but this was no longer helping. A junior doctor from the trauma and orthopaedic team reviewed her at 3.30am (7 November) who noted swelling and mild tenderness. They discussed Mrs A with the orthopaedic registrar and planned for her to go home and return to the fracture clinic later that morning at 10.30am. The records note Mrs A was happy with this plan.
28. Mrs A then attended the fracture clinic later that morning and she had an X-ray which a consultant reviewed. They advised her elbow brace needed reapplying and the plaster room reapplied her brace for her.
29. Our adviser said Mrs A’s brace likely needed reapplying or adjusting but the junior doctor from the trauma and orthopaedic team was not able to do this themselves. Following advice from the orthopaedic registrar they arranged an appointment for Mrs A later that morning. This was approximately seven hours after her review in A&E by the trauma and orthopaedic team.
30. Our adviser said the decision about when to remove the brace is based on clinical judgement of Mrs A’s specific circumstances. They said if there were any delays in getting her an outpatient appointment, then it may have been appropriate to remove her brace in A&E. But, the notes do not suggest her pain was excessive because the junior doctor noted mild tenderness. So it seems it was appropriate to arrange the appointment to remove the brace for later that morning.
31. Having carefully considered the available evidence, we cannot say staff should have removed Mrs A’s hinged brace while she was in A&E. GMC guidance says doctors must recognise and work within the limits of their competence and consult colleagues where appropriate. The junior doctor from the trauma and orthopaedic team discussed Mrs A with a more senior colleague. They then planned for her to go home and return to the fracture clinic around seven hours later. We acknowledge Mrs A was in pain during this time and the wait must have been really difficult for her. She has also given us photographs to show how swollen her hand was at the time.
32. As the notes do not suggest Mrs A reported excessive pain, we cannot say the Trust should have taken further steps to remove her brace straight away. We also do not know whether the Trust would have had the staff available to do this immediately. Based on the evidence we have seen, we think the Trust acted in line with the GMC guidance.
33. As we have not seen that anything went seriously wrong with this part of the complaint, we do not need the Trust to take any further action.