18. 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 for the following parts of the complaint and have not found any indications that something has gone wrong.
Plaster cast
19. Mr H said the Trust fitted him with a plaster cast that was too tight and caused pain and swelling to his fingers. Mr H said he felt numbness in his fingers and pain in his hand in the days following the plaster cast being fitted in the Fracture Clinic on 1 August. He said on his follow up appointment on 8 August, he mentioned to the consultant that he was experiencing pain, discomfort, discolouring and circulation issues in his fingers, but the consultant did not do anything about this.
20. Mr H said he had to attend the ED on 17 August, nine days after his second appointment at the Fracture Clinic, as his symptoms had worsened. He said ED staff removed his cast and fitted him with a new one, they also prescribed him with painkillers.
21. The Trust said that it had reviewed the clinical records from Mr H’s attendance and said his presentation did not fit with a classic acute pain or fracture pain.
22. It said the records show the consultant checked the circulation to Mr H’s arm and there were no concerns with this.
23. The records from Mr H’s first appointment at the Fracture Clinic on 1 August 2022 show staff in the ED had already fitted him with a below elbow plaster cast which was described as fitting very well.
24. Our orthopaedic adviser confirmed this is the correct type of cast for Mr H’s injury and is commonly used for treating fractures in the wrist and forearm.
25. The records of Mr H’s second appointment at the Fracture Clinic on 8 August show the consultant did a thorough and robust examination of his arm to make sure the position of the fracture was still satisfactory.
26. GMC good medical practice guidance says:
‘Good clinical care must include adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors, and where necessary, examining the patient).’
27. Our adviser said the consultant appears to have comprehensively examined Mr H’s injury, in line with good medical practice. The adviser said while some pain and swelling were to be expected so soon after such a significant injury, there was no reason to change Mr H’s cast on 8 August, based on the evidence available.
28. We recognise Mr H’s view that he raised concerns about circulation with the consultant during this appointment, and he felt the consultant did not listen to him.
29. We have not seen any evidence from the records that shows Mr H mentioned any issues with circulation and swelling to the consultant during this appointment.
30. We do not doubt Mr H’s account of the events. However, there is limited evidence available for us to come to a view on whether the consultant dismissed Mr H’s symptoms. We hope Mr H is reassured that the clinical actions of the consultant were appropriate for his injury.
31. The Trust also explained that it had shared Mr H’s concerns in relation to feeling like the consultant had not listened to him, and the consultant had apologised for this and said it was not his intention to leave Mr H feeling this way.
32. Our principles of good complaint handling say organisations should be open and honest when accounting for their decisions and actions. We are pleased the Trust has reflected on where it can improve with regard to communicating and listening to patients and its actions are in line with our principles.
33. We understand Mr H’s view that he had to go to the ED on 17 August and the staff replaced his cast. We appreciate Mr H felt the consultant should have done this the week before.
34. The records of Mr H’s ED attendance show he presented with increased swelling in his fingers and pain to his wrist, and there was also some concern about swelling to his feet. The ED staff split the plaster cast to relieve the pressure.
35. Our adviser said as there was no evidence from the records of these symptoms on the clinic appointment on 8 August, the Trust acted as soon as it was possible to relieve this pressure.
36. The adviser said there is no evidence from the records once staff had taken the cast off that Mr H was suffering from compartment syndrome (an increase in pressure inside a muscle which restricts blood flow and causes pain). It is likely that the increased pain was related to the injury itself.
Pain medication
37. Mr H also said he asked the consultant at the Fracture Clinic to prescribe him with pain killers and said the consultant refused to do so.
38. The Trust said it is usual practice for patients with complex comorbidities, to be managed from a medication perspective on an individual basis by their GP.
39. GMC Good medical practice guidance also says:
‘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’.
40. Our adviser said in a situation where the consultant was not aware of any other treatments or medications the patient was receiving, it was safe and in line with good medical practice for the consultant not to prescribe Mr H with any painkillers and instead refer him to his GP for this.
41. The adviser said the consultant would have been unsure of any potential side effects or how any potential medications would interact with any that Mr H was already taking.
42. We acknowledge that Mr H was suffering with pain in his hand and fingers and wanted the consultant to address this. We hope Mr H is reassured that the consultant’s actions were correct in referring him to his GP for the medication to manage this.
Blood sample
43. Mr H said nursing staff treated him roughly in a follow up appointment in January 2023 which caused further pain to his fingers. He said a staff member abused him by persistently pulling at his middle finger, which caused him pain and discolouration in his fingers.
44. The Trust explained that Mr H had attended an appointment at the Diabetes Centre and staff needed to take a blood sample from his finger. The Trust said to do this, it is sometimes necessary to use a technique called milking, where the finger is gently pulled in a downwards motion away from the body to encourage blood flow to the finger.
45. The Trust acknowledged that this procedure can result in some discomfort, but it was important that the reading from Mr H’s blood sample was available at the time of his consultation.
46. The Trust apologised if Mr H suffered with discomfort and that staff did not explain the procedure properly to him.
47. We acknowledge Mr H may have suffered more pain than he was expecting during this appointment and that this worried him. We are pleased to see the Trust has acted in line with our principles in apologising for any discomfort this experience caused Mr H.
48. We have carefully considered if there is anything more we can add to what the Trust has already done in addressing this. We consider the impact of this complaint does not meet the threshold for us to investigate any further.
Conclusion
49. We understand Mr H suffered a significant injury to his hand and wrist that caused him to experience pain in the months following. We recognise his view that the Trust did not do enough to manage his pain in his follow up appointments.
50. We hope our decision will reassure Mr H that the Trust treated his injury correctly in line with standards and guidelines.