23. Mr O attended A&E after falling into a blackthorn bush/hedge on 20 February 2023. He says the Trust failed to diagnose a blackthorn stuck in his right wrist and delayed treatment.
24. Our adviser referred us to the BMJ journals, emergency medicine journal, blackthorn injury: a report of three interesting cases, volume 21, issue 3. It says ‘blackthorn is well known for causing infections and tissue reactions of synovial structures. Three interesting cases of cystic blackthorn granuloma, blackthorn synovitis with digital nerve entrapment, and multiple blackthorn syndrome are presented. Removal of foreign body fragments and surrounding reactive tissues immediately, resulted in an uneventful recovery with full return of joint and tendon functions’.
25. GMC Good Medical Practice says doctors should ‘provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must work in partnership with them to assess their needs and priorities. The investigation or treatment you propose, provide or arrange must be based on this assessment, and on your clinical judgement about the likely effectiveness of the treatment options’. It also says, ‘promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.
26. From review of the medical records, it is recorded that Mr O attended A&E on 20 February 2023. ‘He reported falling two weeks ago, walking in a country lane, moved to avoid incoming car and fell into a hedge. Fell onto right wrist. Thorn sustained, he thought he had managed to remove them all. He went on holiday and remains painful, red and swollen’. No fracture was confirmed following X-ray and he was given a suspected diagnosis of foreign body under skin.
27. Mr O said he fell into a blackthorn bush/hedge. Our adviser explained that given the history and the presentation of symptoms it was likely that a foreign body was present in Mr O’s right hand. From review of the medical records, it is noted that it was a few weeks since Mr O had fallen into the bush/hedge and he was still having symptoms. Taking this into account, along with the description of falling into a hedge and that Mr O had removed some thorn’s, a blackthorn should have been considered. This would have been in accordance with GMC good medical practice.
28. Our adviser said ultrasound is very accurate in terms of making the diagnosis of a non-radiopaque (material that are not visible on X-ray) foreign body, particularly plant material.
29. It is our view that given the likelihood of a retained foreign body was very high, an ultrasound should have been carried out straightaway. This would be in accordance with the above GMC guidance and journal.
30. From review of the medical records, Mr O returned to the Trust with ongoing symptoms and an ultrasound scan was arranged in May 2023. This confirmed the diagnosis of a foreign body close to the right little finger.
31. We have decided that an ultrasound scan should have been carried out on the date of Mr O’s first attendance at A&E. The emergency medicine journal tells us that a blackthorn is well known for causing infections and tissue reactions. It is our view the Trust delayed an ultrasound scan, which delayed a diagnosis and subsequently delayed treatment. Had the ultrasound scan been carried out earlier, treatment could have started sooner than it did. This would have been in line with GMC good medical practice.
Impact
32. Mr O was born on 28 May 1953 and is 71 years old. He is retired, lives alone with other medical conditions by way of a back problem. He is no longer able to use his fingers fully or close his hand into a fist. He is now partially disabled as a result of the events. Mr O had no hand problems prior to the event.
33. Mr O has told us that he has problems with dexterity. From review of the medical records, we can see that he attended hand therapy on 10 October 2023 and the pressure tests showed concerns with the amount of grip strength available in the right hand. This was less than his left hand. The hand therapy records say Mr O is struggling to flex his little finger and ring fingers. He is now struggling to play the piano and grip items. The Trust advised Mr O about hand exercises. He has done these exercises which have not helped.
34. We know the thorn was 25mm long. Mr O told us his hand is stiff and he cannot open and close it fully in the morning. This gets a bit better throughout the day. He describes difficultly with simple things such as holding a pen, fork, threading a needle, unscrewing a bottle cap, turning on and off taps. He also told us of problems holding and manipulating devices like saucepans and kettles where there is an element of danger from scalding because he does not have the strength or tighten enough grip to lift them properly or safely. He lives alone and is entirely dependent on his own resources. He struggles with using computer keyboards. He is also waiting for major spinal surgery on his back. He accepts this does add a further layer of difficulty, pain and depression in respect of his overall wellbeing.
35. There are two elements of these events that have contributed to Mr O’s ongoing hand problems. The first is the length of time it took to diagnose the thorn and remove it. The second is that, unfortunately, he developed a post operative haematoma which is a complication of any form of surgical treatment. The risk was outlined within the surgery consent form.
36. The emergency medicine journal tells us that a blackthorn is well known for causing infections and tissue reactions. We have found that the Trust should have carried out an ultrasound straight away and diagnosed the thorn sooner. This would have led to earlier diagnosis and removal of the thorn at the earliest possible opportunity, and this was not done.
37. It is our view that part of the disability was avoidable, by arranging an immediate ultrasound which would have led to removal of the thorn. The second part was unavoidable, due to the post operative haematoma which is a complication of any form of surgical treatment. We do not underestimate the impact the events have had on Mr O and the ongoing disability he suffers from. We understand this impacts his day-to-day life, this must be very distressing for Mr O. We cannot say that the failings we have identified are the sole cause of the ongoing problems Mr O has. What we can say, is that the failings we have identified have contributed to Mr O’s ongoing symptoms. He lost out on the opportunity for a better clinical outcome.
38. Mr O would like an apology and acknowledgement, along with a financial remedy. When considering the injustice, we have considered what action the Trust has taken. Within the complaint response letter form the Trust, it did not accept any fault and have therefore not apologised or considered a financial remedy.
39. In determining an appropriate amount of financial remedy to recommend, we use our scale of severity of injustice (SOI) which allows us to ensure the recommendations we make are consistent and transparent for everyone. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend. Our scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstance.
40. In considering our SOI scale, in our view this complaint falls within a level four injustice. Our guidance refers to cases that have a significant and/or lasting impact on the person affected, such that it affects their ability to live a relatively normal life to some extent. The guidance refers to a loss of opportunity for better clinical outcome in cases of moderately serious illness where there is no reduction in life expectancy.
41. We feel this case falls towards the top of this bracket because the failings we have identified contributed to the impact. If the Trust had arranged an immediate ultrasound and removed the thorn earlier than it did, this would have provided an opportunity for a better clinical outcome. Mr O’s life expectancy has not been reduced, but he has been left with serious illness and ongoing disability in his right hand.