17. Ms A says the Trust should have diagnosed her mother’s hip fracture in the ED. It should not have discharged her home without treatment. She says the Trust did not recognise her mother’s lack of capacity to report her pain and it should have given her an X-ray. The next day, a different hospital found Mrs C had a fractured hip, for which she needed surgery.
18. The Trust said the ED consultant and ED clinical director reviewed Mrs C’s care and noted that there was limited clinical suggestion of a broken hip. Her vital signs were within the normal limits. She saw a junior doctor who found no signs of injury to the head and Mrs C was moving all four limbs freely. There was no pain on pressing of the hip joint. The consultant and clinical director said the junior doctor’s assessment was comprehensive. Clinical staff must restrict X-rays to those who clinically qualify for one, due to the risks of exposure to radiation.
19. The GMC’s ‘Good medical practice’ says that in providing clinical care, medical professionals must adequately assess a patient’s condition(s), taking account of their history, carry out a physical examination where necessary, promptly provide (or arrange) suitable advice, investigation or treatment where necessary and consult colleagues or seek advice from a supervising clinician, where appropriate.
20. We can see in line with this standard, the junior doctor examined Mrs C promptly (within an hour of triage) and discussed her with a more senior doctor following the assessment (plan to discharge her back to the care home). We consider this to be in line with the GMC guidance.
21. However, we know Mrs C had vascular dementia. Pain responsiveness in patients with dementia can be variable.
22. We recognise there was no formal capacity assessment, but our adviser said it is more likely than not that Mrs C lacked capacity at this time due to her recorded dementia. In a patient who lacks capacity a best interest approach should be adopted in line with the GMC guidance on decision making and consent.
23. Paragraph 87 of this guidance describes the ethical basis on which decisions are made about treatment and care for the benefit of adult patients who lack capacity to decide for themselves. This involves weighing up the risks of harm and potential benefits for the individual patient of each of the available options, including the option of taking no action.
24. Our ED adviser said if the Trust had done this for Mrs C it would have indicated the need for an X-ray of the right hip and pelvis because of the specific complaint at triage of right hip pain. A full assessment would have been difficult due to Mrs C’s dementia. Our adviser said the issue of radiation dose was not clinically relevant.
25. Our ED adviser said the only reason not to do the X-ray would have been if Mrs C had been up and walking about in the ED. The records only state ‘mobilising’, but with no details of how. A good assessment in line with Good Medical Practice would have included if she had been walking and pain free, but the entry lacks these details. There is no indication the Trust contacted the nursing home to confirm any history of Mrs C mobilising since the fall. So based on the information we have seen, there was no evidence to support a decision not to do an X-ray.
26. We have found a failing here. We do not think the Trust acted in line with the GMC guidance when it decided to discharge Mrs C on 27 July 2023 without doing an X-ray. We next considered the impact of this.
Impact
27. Ms A says Hospital B found her mother had a fractured hip, for which she needed surgery. Ms A says left her mother is now immobile and has significant problems with her hips and legs. She has had to move into a care home permanently, away from her family. She thinks her mother could have returned home after respite if the Trust had diagnosed her.
28. The experience in the ED and not being able to communicate her pain caused her mother additional confusion, stress and anxiety. Ms A is disappointed and disgusted with the way the Trust neglected her mother. She has lost faith in the Trust.
29. We do not underestimate her concerns. It is important to note that even if the Trust had done an X-ray on 27 July, we cannot say that it would have shown a fracture.
30. We know on 28 July Mrs C went to Hospital B. She presented with right hip pain and inability to weight bear. An X-ray showed an oblique, communited intertrochanteric fracture (type of broken hip) of the right neck of femur, following which she had surgery. Our adviser said if Mrs C had had this fracture on 27 July, it is very unlikely she would have been able to mobilise. But we cannot know if she did have the fracture. Our orthopaedic adviser said it is possible she sustained this at some point between the two hospital visits. We can see this may have, for example, happened during her transfer back to the care home or into bed.
31. We contacted the care home for the records between 27 and 28 July to see if these provide any further evidence of what was happening during this period. Unfortunately the home could not locate the file in its archive. We only know that by the time Mrs A visited her mother, Mrs C was in bed, in pain and unable to move. But the evidence we have seen does not allow us to say when she had a fracture.
32. This means we cannot say, on the balance of probabilities, that if the Trust had done an X-ray it would have found a fracture and taken different action. It is possible the Trust would have done the same thing after an X-ray and discharged her back to the care home.
33. We note Ms A says the surgeon who operated on her mother told her the operation was more complicated because of the delay. We acknowledge her account and how upsetting this was for her. We have looked at Hospital B’s records. There are no entries indicating that the surgeon documented this view or to suggest the operation was more difficult than it should have been.
34. We would like to share some additional comments from our orthopaedic adviser. They said that if an X-ray on 27 July had shown a fracture, and Mrs C had had surgery straight away, regrettably it is likely she would always have had the same outcome. Our orthopaedic adviser said that when elderly patients break their hip, they almost always get worse. Their mobility levels decrease, and they almost never return to the same level of activity they had before. We share this information to show that regrettably it is unlikely Mrs C could have avoided her long-term mobility, hip and leg problems. It is clear from Mrs A’s account how awful it was for the family to see Mrs C go downhill so quickly, both in her physical condition and her dementia. We hope they are reassured this was not because of the Trust’s mistakes.
35. However, we recognise that Mrs A is left never knowing if the right action would have made a difference, if not in the long-term, at the time to relieve some of Mrs C’s pain and distress. This is an injustice in itself. Mrs A says she and her family have lost faith in the Trust. She knows the Trust made a mistake in not doing an X-ray and we think this contributed to them feeling that way.
What the Trust has done to put things right
36. The Trust said the junior doctor’s assessment was comprehensive and it was right for them to discharge Mrs C without performing an X-ray. The Trust also said Mrs C’s expression of pain may have inadvertently been overlooked, but do not feel this would have tipped the balance for an X-ray. It made attempts to get a baseline from Mrs C which it considered to be good practice. It said she was mobilising in the ED, so the likelihood is she did not have a surgically treatable fracture then.
37. The Trust has told us about its work on caring for dementia patients. It has educated nurses on picking up trauma at triage and getting senior intervention and primary survey early. It has implemented some changes with regards to ‘silver trauma’, which includes early identification and management of trauma in elderly patients.
38. We are pleased to see the Trust has thought about how it could learn from this complaint. This is welcoming learning. However, we do not think it is enough.
39. The Trust has not acknowledged that it should have done an X-ray and that this has had some impact on Mrs C, Mrs A and the family.