15. 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. If we see evidence of this, we look at whether there are signs the events complained about, had a negative effect, which the organisation has not put right.
Diagnosis and treatment
16. Ms B complains the Trust did not identify the severity of her mother, Mrs F’s broken shoulder in June 2023 and did not put a follow up plan in place. We were sorry to hear about Mrs F’s experience and the impact this had on her daughter. Understandably, she feels like this was avoidable as her mother went on to experience ongoing pain and had surgery several months later.
17. The NHS website says if someone presents to the ED with a suspected broken arm or wrist, an X-ray is used to see if there is a break and how bad that break is. GMC also says promptly provide or arrange suitable advice, investigations or treatment where necessary.
18. Mrs F attended the Trust’s ED on 4 June with right shoulder and hip pain following an unwitnessed fall at home. The Trust carried out X-ray of her right shoulder from two different angles and it diagnosed her with a minimally displaced fracture at the top of her right arm. It noted her fracture would be treated non-surgically and provided her with a collar and cuff sling.
19. It decided to admit Mrs F for a full functional assessment and discussion with her family, as it did not think it was safe for her to be discharged with her current home setup.
20. During her admission its orthopaedic and therapy teams reviewed Mrs F, and they thought she would benefit from a period of time in rehabilitation. It wrote to her GP to explain she had been discharged on 9 June to a community hospital for rehabilitation and asked it to review her pain medication in a few weeks.
21. Our adviser explains the X-rays the Trust took showed a minimally displaced fracture at the top of her right arm. They say the Trust took X-rays of Mrs F’s shoulder from two different viewpoints which demonstrate the fracture it described. They went on to say there is no indication further imaging or investigation was required at this time.
22. Based on the evidence we have seen, it appears the Trust followed GMC guidance when it carried out prompt investigations to find the source of Mrs F’s pain following her fall. We can see it carried out an X-ray as explained by NHS website and identified the fracture on the day she presented to its ED. Therefore, we cannot see it got anything wrong with the way it identified her fracture and there are no indications further investigations were needed.
23. We have also considered Ms B’s concerns that the Trust did not put a follow up plan in place to manage her mother’s fracture. It is clear from what Ms B has told us that this was a difficult time for her mother as she could not use her right arm for anything, which we are sorry to hear about.
24. NICE guidance for adults with displaced fractures says offer non-surgical management for definitive treatment of uncomplicated injuries and consider surgery for injuries complicated by an open wound, tenting of the skin, vascular injury, fracture dislocation or a split of the humeral head.
25. NICE guidance on rehabilitation says after a traumatic injury, assess the person's rehabilitation needs as an integral part of their care pathway from admission. This may include discussing findings from early rehabilitation assessments with the person, and their family members or carers. It goes on to say avoid delays in acute treatment so that rehabilitation can start as soon as possible, for example, to maintain movement.
26. As noted above we can see after the Trust identified Mrs F’s fracture on 4 June, it noted she would be treated non-surgically which appears to be in line with NICE guidelines as there did not appear to be any evidence her injury was complicated by any factors indicated by NICE.
27. The Trust provided her with a collar and cuff sling. We can see the Trust’s physiotherapy team assessed her on 4 June and decided to admit her. It called Mrs F’s daughter to explain she had been admitted and the reasons for this.
28. An occupational therapist assessed her on 7 June. They noted she was not at her typical level of mobility and referred her for ongoing therapy at a community hospital. It discharged her on 9 June to a community hospital for further rehabilitation.
29. Our adviser explains in Mrs F’s case the standard method of treatment is non-operative management. They say this is because the risks of surgery would outweigh any possible benefit from surgery, which they explain the benefits could be very minimal. They went on to explain the Trust used a standard management plan for this type of injury.
30. Based on the evidence we have seen, it appears the Trust’s actions were in line with NICE guidelines on managing her fracture when it decided to treat Mrs F non-surgically. We can also see it followed NICE guidelines on rehabilitation when it assessed her rehabilitation needs on 4 June and discussed this her and her daughter. We can also see it referred her to the community hospital for rehabilitation and follow up care on 7 June, three days after her admission. Therefore, appears it did not delay Mrs F’s from getting therapy to improve her mobility.
31. Understandably Ms B is concerned as her mother went on to experience a haematoma in her right shoulder in November which she needed urgent surgery for. There is no evidence to suggest Mrs F had symptoms of a haematoma earlier than this. Mrs F’s records show the X-ray the Trust carried out indicated her fracture was healing in July. When she presented to it in October and it carried out a repeat X-ray which showed no change from July, it referred her to the outpatient fracture clinic.
32. There does not appear to be evidence to show Mrs F attended the Trust between July and October. Therefore, we cannot say the Trust should have identified any complications caused by Mrs F’s fracture earlier than it did, as she did not present with these symptoms until November.
33. We do not underestimate Ms B’s mother’s experience and the impact it had on them both. It is clear she feels the Trust should have provided her mother with a more thorough follow up care plan.
34. We are satisfied the Trust did not get anything wrong and followed guidance when it identified Mrs F’s fracture on 4 June and arranged for her to receive follow up care at a community hospital. We will therefore not take further action on this complaint. We understand Ms B’s experience has caused her great distress and we are sorry to hear about this.
Pain management
35. Ms B says the Trust did not manage her mother’s pain in October and November when she attended it several times. We are sorry to hear Ms B felt ignored and disrespected by the Trust. We do not underestimate her mother’s experience and the impact it had on them both, as Ms B told us she had to give up work to care for her mother.
36. Our adviser explains there are no specific guidelines for managing pain specifically related to the fracture Mrs F had. However, they say we can refer to NICE guidelines for adults with displaced fractures which say pain should be assessed regularly in people with fractures using a pain assessment scale. Whilst in hospital, pain should be assessed using the same pain assessment scale that was used in the prehospital setting.
37. Based on the records we have seen, it appears the Trust used the numerical pain rating scale (NPRS) which the BPS explains is a validated structured pain assessment tool. It is scored from zero to ten, zero indicating no pain and ten the worst possible pain. It says the score can be correlated to the severity of pain, for example mild pain is less than three and more severe pain is six or higher.
38. Mrs F’s records show she attended the Trust on 20 October. It initially assessed her at approximately 3.55pm. It noted bruising and pain around her right shoulder. It carried out blood tests and found her haemoglobin levels were low. This is commonly known as anaemia and means there are less red blood cells to carry oxygen around the body. It planned to carry out a blood transfusion to address this.
39. We can see it noted Mrs F’s pain score as zero at around 6.40pm. It carried out the blood transfusion and she self-discharged when it had been completed. There is no evidence in the records which suggests Mrs F reported any pain before she self-discharged. Based on this information it appears the Trust recorded Mrs F’s pain score during this attendance which is in line with NICE guidelines. As the pain score it recorded was zero, it does not appear the Trust offered any pain medication. Therefore, it does not appear the Trust got anything wrong during this admission.
40. We went on to consider another occasion when Mrs F presented at the Trust on 10 November with extreme shoulder pain. It admitted her and planned to manage her pain along with input from orthopaedics.
41. Mrs F was an inpatient at the Trust, up to the evening on 15 November. The records show it prescribed and regularly administered paracetamol and oxycodone throughout her admission. Oxycodone is a painkiller used to treat severe pain. We can also see it referred her to the pain team on 12 November.
42. It assessed her on 13 November. It noted she was experiencing pain at that time, and it agreed to introduce pregabalin, which is used to treat nerve pain. It also advised to continue with paracetamol and oxycodone. We can see the Trust prescribed pregabalin in line with the pain team’s advice and administered this daily up to 15 November.
43. During her admission we can see the Trust recorded her pain score approximately 21 times. Of those it noted a score higher than zero, on six occasions. The records show each time she reported a score of higher than zero, the next time it recorded her pain score it had reduced to zero. For example, at 10.12am on 11 November it noted Mrs F’s pain score was eight. It administered oxycodone and paracetamol. It noted her pain score as zero at 1.41pm.
44. Our adviser explains this is standard management for the pain associated with the fracture Mrs F had sustained.
45. Based on the evidence it appears the Trust followed NICE guidelines when it regularly used a pain assessment scale to assess Mrs F’s pain during her admission between 10 and 15 November. We can see each time it recorded a pain score higher than zero, her pain had reduced to zero when it next recorded it. This suggests the medication the Trust gave to Mrs F was managing the pain she reported.
46. It is clear from what Ms B has told us, she feels the Trust ignored her mother’s reports of pain. We are sorry to hear how difficult this was for her to witness and how she is still coming to terms with what her mother went through. We do not underestimate how difficult it must have been to relive these events and explain her complaint to us. We are grateful for the time and effort she has taken to do this.
47. Overall, based on the evidence we have seen, we are satisfied the Trust did not get anything wrong and followed guidance when it regularly assessed Mrs F’s pain during her admissions in October and November 2023. We can also see it regularly administered pain medication which the records indicate managed her pain. We will therefore not take further action on this complaint.
48. Understandably from what Ms B has told us her mother’s experience has caused her great distress, and we are sorry to hear about this. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Trust has taken her complaint seriously.