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Gloucestershire Hospitals NHS Foundation Trust

P-003030 · Statement · Decision date: 21 October 2024 · View Gloucestershire NHS Trust scorecard
Complaint (AI summary)
Ms A complained a consultant misdiagnosed a dislocated kneecap, failed to examine her knee, and dismissed her pain as psychological, leading to prolonged suffering and necessary surgery.
Outcome (AI summary)
Complaint closed. No evidence indicated an incorrect diagnosis or a necessary physical examination. No conclusion could be reached on the consultant's attitude.

Full decision details

The Complaint

5. Ms A complains about the Trust. Specifically, she complains on 11 May 2023 the consultant failed to diagnose a dislocated kneecap and did not carry out a physical examination of her knee.

6. Ms A also complains the consultant said it was her mind that was causing her to think she was in pain as there was nothing wrong with her knee.

7. Ms A says the misdiagnosis and the consultant not carrying out a physical examination of her knee caused her severe pain for longer and she was unable to work. As a result, she had to seek a second opinion, privately. This led to her being diagnosed with a dislocated kneecap that required surgery. Ms A says she had to have her old screws removed as these had moved causing more damage to the inside of her knee.

8. Ms A says the attitude of the consultant left her feeling humiliated.

9. Ms a wants an apology, acknowledgment of failings, and a financial remedy.

Background

10. On 8 March 2023, Ms A attended the emergency department (ED) as she had twisted her knee. A referral was made for a magnetic resonance imagining scan (MRI scan).

11. On 28 March, Ms A had an MRI scan.

12. On 11 May, Ms A was given the results of her MRI scan. She was diagnosed with a partial dislocation of her knee.

Findings

16. Before we decide if we should conduct 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 found any indications that something has gone wrong.

Diagnosis and physical examination

17. Ms A complains the consultant failed to diagnose a dislocated kneecap.

18. The Trust said most patella dislocations are managed with physiotherapy as lateral release is no longer recommended as best practice.

19. The clinical records show Ms A was diagnosed with a patella subluxation. This is a partial dislocation rather than a full dislocation. Our adviser said this was an appropriate diagnosis based on the results of Ms A’s MRI scan on 11 May.

20. Our adviser has explained there is no UK guidelines on the management of patella dislocations.

21. PMC literature says, ‘conservative management following a patellar dislocation is recommended when imaging does not detect chondral lesions, osteochondral fragments or serious injuries of the parapatellar ligament complex’. The literature also says, ‘most people with patellar dislocations do not need surgery, and isolated lateral release is never indicated, but clinicians should be aware of the possibility of osteochondral fractures after dislocation’.

22. The clinical records show Ms A had no lesions, fragments or serious injuries of a ligament complex. Her medial and lateral collateral were normal, her tendons were normal, and her anterior and posterior cruciate ligaments were also normal.

23. Our adviser says literature supports initial non-operative management, and therefore Ms A was offered the correct treatment of physiotherapy for her condition.

24. We recognise the amount of pain Ms A was experiencing. We consider the Trust diagnosis was appropriate based on the results of her MRI scan.

25. Ms A also complains the consultant did not carry out a physical examination of her knee.

26. GMC guidance says in providing clinical care you must:

• carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary

27. The clinical records show a physical examination of Ms A’s knee was undertaken on 14 March. However, our adviser has said it is unlikely a physical examination was done on 11 May, as this was to discuss the findings of the MRI scan. Our adviser has said a physical examination is not necessary on each occasion, and even if one had been done it is unlikely to have changed the management plan from a referral to physiotherapy.

28. We recognise Ms A was in pain and expected the consultant to carry out a physical examination of her knee. The clinical records indicate this appointment was to discuss the findings of Ms A’s MRI scan. We recognise GMC guidance says to carry out a physical examination where necessary, it does not say a physical examination must be done. The evidence also shows following Ms A’s diagnosis the consultant referred her for physiotherapy. We consider the Trust acted in accordance with GMC guidance.

Attitude of the consultant

29. Ms A also complains the consultant said it was her mind that was causing her to think she was in pain as there was nothing wrong with her knee.

30. From the medical records we have, there is nothing recorded to indicate the consultant said this to Ms A.

31. We have considered whether we would be able to reach a decision regarding this issue. Having done so, even on balance, we cannot reach a view on whether this is what the consultant said to Ms A. This is because we have no way to determine whether Ms A’s account is correct.

32. Therefore, we are unable to reach a conclusion about what happened, and we will be taking no further action with this issue.

33. We thank Ms A for bringing her complaint to us for consideration. We appreciate how difficult it must be for her to go through the details of her complaint again.

Our Decision

1. We have carefully considered Ms A’s complaint about Gloucestershire Hospitals NHS Foundation Trust (the Trust). We are sorry to hear of Ms A’s experience and the pain and distress this has caused her.

2. We have looked at the evidence provided by Ms A and the Trust and having thought about the issues carefully, we consider there is no evidence to indicate an incorrect diagnosis or that a physical examination of the knee had to be done.

3. We have decided we would likely not be able to reach a decision about the attitude of the consultant and what he said to Ms A.

4. We understand our decision may be disappointing to Ms A. We are sorry we cannot help her further. We have explained our decision in more detail below.

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