11. Before we decide if we should do 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 found no indications something has gone wrong.
12. Mr H complains after his wife suffered an unwitnessed fall; the Trust did not escalate her properly. He says it took three days for the Trust to take her to hospital. He does not believe his wife could have been mobilising with a fractured pelvis that needed immediate surgery.
13. The Trust says Mrs H was at once referred for an assessment with a doctor after a nurse found her on the floor. The Trust saw no obvious sign of injury so there was no reason to refer her until the following day when there was a sign something was wrong.
14. NICE QS86 says people who fall as an inpatient should be checked for signs of fracture or spinal injury and have a medical examination. It says staff should check if either leg is shortened, deformed or externally rotated, if the patient is complaining of pain and if they can mobilise each leg. These examinations should be done within 12 hours.
15. When we look at the records, we can see Mrs H fell in the early evening and was assessed shortly afterwards. The Trust referred Mrs H to A&E the next day, just under 24 hours afterwards. We hope Mr H is reassured his wife was not waiting for three days after her fall to go to A&E. The Trust examined Mrs H three times in this period and continually monitored her. This means the Trust acted within the expected timeframes and in line with national guidance.
16. From the first physical assessment taken shortly after Mrs H fell and the second visual assessment done the following morning, there was no shortening or external rotation of either leg and she was able to mobilise both legs. While there was no physical sign of injury or fracture, the Trust prescribed pain relief and planned to monitor her. Our adviser confirmed this action plan was in line with good clinical practice, given her presentation, and there was no obvious need for an urgent X-ray at this point. The Trust’s actions here appear to have been in keeping with the RCP flow chart for falls decision making, and in line with the NICE guidance.
17. As the day progressed nurses referred Mrs H to a doctor again as she was in pain and refusing food. During the third assessment the clinician saw swelling over her left hip. Although Mrs H was able to move both legs, she was still indicating it was painful, so a mental health doctor referred her to a hospital A&E for an X-ray. This showed she had a pelvic fracture.
18. We asked our adviser if it was possible Mrs H could mobilise with a pelvic fracture. They confirmed mobilising even with a fracture is quite common. To justify exposure to radiation from X-rays there must be signs and symptoms one is needed (that is, signs of sinister injury such as deformity, significant pain and inability to weight bear). Sometimes after a fall or significant injury the person can have a rush of adrenaline which may provide a temporary surge of strength or numb pain after fracture, enabling initial movement. Their inhibited ability to mobilise or weight bear may only present over time.
19. So, the fact Mrs H had a fractured femur the day after her fall does not mean she would have shown signs of this straight away.
20. Overall, when we look at the complaint, advice, medical notes and guidance we can see no indication the Trust did something wrong. The Trust did assessments, made an action plan and did a referral to A&E appropriately within those 24 hours. We also cannot say her ability to mobilise on assessment undermined the quality of the examinations she had. The Trust continually monitored Mrs H, gave her pain relief and escalated her in the 24 hours before she was referred to hospital.
21. It is clear from Mr H’s account how difficult these events were for him and his wife. We do not intend for our decision to take away from that. We sincerely hope he can take some reassurance from our view that, overall, the Trust acted in line with its duty of care on these issues.
22. We appreciate it may have been difficult to revisit these issues when he came to us. We want to extend our gratitude for him bringing this complaint to us and hope we have clearly explained how we reached our views.