Misdiagnosis of stress fracture
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.
17. Ms R attended her fracture clinic appointment on 24 October 2023 following her X-ray in the Emergency Department (ED) on 17 October. During this appointment, the consultant diagnosed her with peroneal tendonitis. The consultant advised to treat the injury conservatively with strapping, painkillers and weight-bearing as tolerated.
18. Following continued pain, Ms R complained to the Trust and had a further appointment at the fracture clinic on 16 January 2024. The consultant ordered a further X-ray and MRI scan. These tests showed a stress fracture of the fibula. Ms Aragoneses Solano told us the consultant apologised this had been missed from her X-ray on 17 October 2023 and said that in hindsight, it was visible.
19. We sought advice from our adviser as to whether the fracture was visible on the X-ray from 17 October 2023. They told us the fracture is not clearly visible. The X-ray report says ‘no acute bony injury seen’ and they said this is a reasonable interpretation of the images.
20. Our adviser explained the Trust’s diagnosis of peroneal tendonitis was also reasonable given the lack of obvious fracture on the X-ray and the examination of Ms R.
21. We also considered the information in the stress fracture report. This is to help explain fibula fractures and not as a guideline for what should have happened. It says the fibula is a low risk site for stress fractures. The report says these fractures usually heal with conservative management which is what was provided anyway to Ms R for the diagnosis of peroneal tendonitis.
22. Good medical practice section 15 says ‘if you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history…where necessary examine the patient and promptly provide or arrange suitable advice, investigations or treatment where necessary’.
23. We consider the Trust acted in line with this guidance. This is because the medical records indicate Ms R was assessed and examined. The records also indicate the Trust made appropriate recommendations for conservative management of her injury, given the fracture was not visible on the X-ray.
24. We recognise The Trust misdiagnosed Ms R’s fracture as peroneal tendonitis, however we are of the view this was not a failing by the Trust. This is because the advice we have received said the fracture was not clearly visible on the X-ray.
25. We consider the Trust acted in line with good medical practice as the treatment was for a reasonable alternative diagnosis and conservative management was the treatment for both peroneal tendonitis and a stress fracture. We have seen no indications of a failing here.
Communicating results of the DEXA scan
26. To decide if we should conduct a detailed investigation into a complaint, we look at what outcome the person coming to us wants to resolve their complaint. Our Service Model Guidance says, in sections 3.57 to 3.65, we can resolve a complaint without conducting a detailed investigation if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case handling process.
27. The consultant ordered a DEXA scan for Ms R after her appointment on 6 February 2024. This was because the stress fracture had occurred without any trauma. A DEXA scan could help detect is she had any osteoporosis (a condition where bone strength weakens, making fractures more likely). Ms R had this scan on 15 February.
28. Ms R says she chased the results of this scan several times with the Trust. She says the Trust told her that responsibility for delivering the results and organising any relevant follow-up treatment lay with her GP. Her GP then told her they could not even see the results, as it was the Trust who had ordered the scan. Ms R told us she felt the Trust was rude and dismissive, refusing to give her the results even though she had made clear her GP had said they did not have them.
29. The Trust relayed the results of the DEXA scan to Ms R during an appointment on 26 March. Ms R says this was only after she refused to leave the consultation room without being told. We have not seen any further evidence about the incident in the medical records or complaint responses. We have focused on the communication of the results, rather than staff rudeness, as there is evidence available for us to form a view on that.
30. We spoke with the Trust to try and establish where the responsibility for giving results lies. The medical records state ‘clinic policy is that the GP is the one who is dealing with the results of the DEXA scan’. The Trust told us originally that the rationale behind the GP relaying scan results is because it is the GP who offers long term management of osteoporosis.
31. The Trust then confirmed there is no policy but if it has ordered the scan, then it should be the Trust who delivers the results, and the GP can then follow-up as required. The Trust has acknowledged the confusion around responsibility for communication of results in these situations. We focused the rest of our consideration on the impact of this and what needs to happen to put that right.
32. We consider the issue caused distress and annoyance to her. Our principles say organisations should acknowledge poor service and apologise for it. Our principles also say organisations should seek continuous improvement, and use lessons learnt from complaints to ensure that poor service is not repeated. It can do this by giving assurances that lessons have been learnt and explanations of changes made.
33. We spoke to the Trust, and it has agreed to take further steps to put things right for Ms R in the form of a further apology for the poor communication of her DEXA scan results. It has also assured us it is now clear who has responsibility to, and how they should communicate results in these situations in the future.
34. We consider the poor communication falls in line with level one of our scale as it has caused a short duration of distress and annoyance but has not affected Ms R’s ability to function or live a normal life during this time.
35. We are satisfied the Trust has now agreed to take appropriate steps, in line with our principles for remedy, to put right the injustice for Ms R. We consider we have resolved this part of her complaint.
36. We recognise Ms R’s experience with the Trust and orthopaedic department was distressing. We hope she is reassured that her concerns have been investigated with independent clinical advice, and the Trust has also acknowledged the poor communication with her.