17. When we look to determine if there was a failing in the care and treatment complained about, we first consider what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if what should have happened, did happened. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to a failing.
18. If we identify there has been a failing in the care and treatment provided, we then consider the impact of this failing. If the failing has had a negative impact on the complainant, we consider what actions the organisation has already taken to put things right. If we consider it has not done enough to put things right, we may make recommendations for further actions.
19. The focus of this complaint is on what the Trust did when Miss C attended A&E for the second time. The clinical notes say the X-ray from the walk-in centre showed a trimalleolar fracture dislocation of the ankle (when the ankle joint breaks in three places) which required urgent manipulation. The clinical notes say the walk-in centre plastered Miss C’s leg and she returned to the Trust at 5.57pm. Miss C says the walk-in centre did not plaster her leg.
20. On arrival at the Trust, it noted Miss C had been sent for right ankle manipulation. It gave her a triage score of four according to the Manchester Triage System which is used by most Trusts to triage patients on arrival. This is classed as a ‘standard’ presentation which means patients should be seen within two hours.
21. Our emergency medicine adviser explained an ankle fracture requiring manipulation is potentially a limb threatening injury. They said this presentation should not have been given a triage score of four, but rather a score of two or three, to be ideally seen within 10 to 60 minutes.
22. Our advisor also said trimalleolar fracture dislocations of the ankle should be treated as an emergency and manipulation should be attempted as soon as possible. BOAST guidance on the management of ankle fractures says that in some instances should even precede an Xray if there is an unacceptable delay getting an X-ray.
23. The Trust did not assess Miss C until 4.40am the following day, around 11 hours after readmission to the Trust and around 17 hours after the injury had taken place.
24. We have found the Trust failed to correctly assess the seriousness of Miss C’s injury and did not give Miss C the correct triage score, delaying her assessment.
25. Even with the triage score the Trust gave to Miss C it should have assessed her within two hours. The Trust said the average waiting times for the day Miss C was admitted was five hours. This was still considerably less than the 11 hours the Trust made Miss C wait before being assessed and treated.
The impact on Miss C
26. In its complaint response the Trust acknowledged it should have prioritised Miss C sooner. We have considered whether the delay had any impact on the extent of the treatment Miss C then required.
27. The Trust carried out a hindfoot nail stabilisation operation on Miss C’s ankle to repair the breaks. Miss C believes this was only necessary because of the delay in manipulation.
28. Our orthopaedic adviser explained Miss C would still have needed surgery, regardless of the delay, as she had suffered a complex and unstable ankle fracture. Although manipulation may have reduced the fracture temporarily, it would not have been enough to repair the break.
29. Our orthopaedic advisor also said the type of surgery carried out would likely have been the same regardless of the delay. The ‘Hindfoot Nails in Trauma’ guidance lists indications for that type of surgery. One of those is that it may prevent wound complications and soft tissue compromise. The Trust’s decision to perform that type of surgery was based on the condition of Miss C’s skin and her recurrent cellulitis, as stated in her clinical records, rather than anything to do with the delay in assessing her.
30. In summary, even without the Trust’s delay in Miss C’s assessment, there would have been no significant difference to the treatment, recovery and prognosis her ankle fracture.
31. We have identified two failings. The Trust incorrectly giving a triage score of four for a potentially limb threatening injury, and then delaying the assessment and treatment of the injury for around 11 hours.
32. We find we cannot link these failings to the claimed impact of having to undergo surgery to repair the ankle. The treatment was based on the type of fracture and the condition of Miss C’s skin and medical history and was not impacted by the delay. We note the Trust has apologised to Miss C for the delay in assessing her.
33. As we have been unable to link the injustice Miss C has told us about, to the failings we have identified, we will not ask the Trust to do anything further.
34. While we have not been able to say the failings identified have led to the impact Miss C has told us she experienced, we partly uphold the complaint because of the failings identified.
35. We recognise Miss C has ongoing difficulties as a result of the ankle fracture and our decision is in no way intended to diminish that. We know this injury has had a significant impact on her mobility.