Issue one- concerns relating to the spinal board and neck brace
24. Mr X tells us that Mrs X suffered a fall at home and accordingly an ambulance was called. He says the paramedics sat Mrs X up and made her stand following which they said ‘this is a good sign’.
25. Mr X says when she arrived at Trust’s A&E, the Trust laid her flat on a spinal board and put her in a neck brace. Mr X specifically complains about the length of time she was in this position for. He says this led to her suffering pulmonary oedema.
26. Mr X tells us at the time his mother was very uncomfortable and complained about breathing problems. He says he also raised concerns to the professionals but was advised to keep the neck brace on. Mr X says because of his mother not being able to breath he took the neck brace off and called for a doctor after which Mrs X was put on oxygen.
27. We are very sorry to hear about how much difficulty Mrs X was in and can appreciate how distressing this must have been for both her and her son, Mr X to witness. We can understand why this complaint is so important to them both.
28. The Trust says in its response dated 18 January 2024 that upon arrival at A&E, the doctor reviewed Mrs X and requested a trauma CT scan to look out for any injuries.
29. It says she was immobilised by being laid on the spinal board and in a neck brace because of a spinal fracture that was suspected. The Trust says these could not be removed until there was a verbal report of Mrs X’s CT scan.
30. The Trust says following Mrs X being found unresponsive at 10.58pm on the 20 October 2023, doctors removed the spinal board and neck brace.
31. We identify that there is a dispute about the version of events relating to who removed the neck brace. Mr X tells us he removed it after telling the professionals that his mother could not breath. The Trust says in its response, the doctors removed it when they felt it was safe to do so when Mrs X’s health deteriorated.
32. Unfortunately, we would not be able to reach a conclusion on who removed this as we have no impartial evidence other than the Trust and Mr X’s account of the events. Saying this, we do not consider this affects our consideration of the issue, specifically whether it was appropriate to keep Mrs X in this position for this length of time.
33. We have obtained clinical advice from the consultant in emergency medicine adviser as well as the orthopaedic and spinal surgeon adviser in relation to this and have been directed to the following guidance.
34. NICE [NG41] guidance, ‘Spinal injury: assessment and initial management’ provides guidance on how to assess and manage suspected spinal injuries.
35. 1.2 of the NG41 guidance states:
‘At all stages of the assessment:
• Protect the person’s cervical spine with manual in-line spinal immobilisation, particularly during any airway intervention and • Avoid moving the remainder of the spine.
36. Section ‘Assessment for cervical spine injury’ says in paragraph 1.1.5: ‘Assess whether the person is at a high, low or no risk for cervical spine injury as follows:
• the person is at high risk if they have at least one of the following highrisk factors: • age 65 years or older • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, highspeed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents) • paraesthesia in the upper or lower limbs.
37. The NICE NG41 guidance says in section 1.1.9:
‘Carry out or maintain full inline spinal immobilisation if: • a high-risk factor for cervical spine injury is identified’
38. Section 1.4.7 also says ‘carry out or maintain full in-line spinal immobilisation and request imaging if a high risk for cervical spine injury is identified.
39. Having carefully considered the above, Mrs X’s clinical notes detail that she had fallen from ‘standing height’ and had injured her ‘head and back’. We can see at the time of the incident Mrs X was 89 years old and is noted to be suffering from Parkinson’s disease (a condition that affects the brain), ischaemic heart disease, pulmonary hypertension (high blood pressure), diabetes and neuropathy (nerve damage). We can also see Mrs X was complaining of thoracic pain (pain in the middle and upper back).
40. Based on the above, specifically because of her age, she was considered to be at a ‘high risk of a cervical spine injury’. It was therefore in line with NICE NG41 guidance specifically section 1.4.7 to immobilise her with a neck brace and spinal board and request a CT scan.
41. The RCEM guidance namely ‘Silver Trauma’, also highlights the need for early scanning and says in section ‘Major Trauma in Older People’ that points professionals should remember to complete ‘early trauma scanning’.
42. We can see that the CT scan was requested at 8.32pm and was completed at 9.19pm. Mrs X was reported to be feeling sick and was given antiemetics at 10.11pm. Following this the records show that she was found unresponsive at 10.58pm.
43. We understand there had been a drop in her oxygen levels and required oxygen to be administered.
44. The clinical entry detail that the CT scan results had not been provided at the time and so a verbal report was requested to ‘support breathing safely’. The notes go on to say that professionals ‘needed to balance out the risk’ before mobilising Mrs X. Following the verbal report of the CT scan confirming there were no injuries ‘the collar was removed urgently and trauma board removed’.
45. We consider it in line with clinical NICE NG41 guidelines for Mrs X to have remained immobilised until the CT scan confirmed that there was no spinal injury.
46. St Johns ambulance says in guidance ‘Spinal cord injury’ that ‘the greatest risk of someone who has a spinal injury is that it will either be temporarily or permanently damaged. If this happens, they may lose sensation or power below the injured area’.
47. Having carefully considered all the available evidence, we find no failings in the Trust’s decision to place Mrs X in a neck brace or on a spinal board. We find no failings in the length of time she remained immobilised, and it was clinically appropriate and in line with guidelines for her to only be moved once the CT report confirmed no injuries to the spine.
48. We do not uphold this part of the complaint.
Issue two- concerns relating to the missed fracture
49. Mr X tells us that the initial CT scan was reported back to show no signs of injury. However, following this an MRI was completed on the 9 November 2023 which showed a fracture to the lower region of her Mrs X’s spine. Mr X complains the Trust missed the fracture during the initial CT scan.
50. The Trust acknowledges in its response dated 18 January 2024 that because of Mrs X’s ‘degenerative spinal changes and very Osteopenic bones’, the fracture in the initial CT scan was difficult to see. However, it acknowledges that regardless, looking at this in retrospect the fracture can be seen. It therefore acknowledges failings in the fracture being missed in the initial CT scan.
51. The Trust has acknowledged, apologised and made service improvements following this failing. We can see further learning from the incident has been proposed and the incident has been discussed directly with the radiologist involved.
52. Mr X says because of the failure to identify the fracture, it was not treated. He says it led to his mother being bedbound since her discharge. We are very sorry to hear about such a serious impact. We understand how important it is for a person to stay mobile and can understand how difficult this must be for Mrs X.
53. The Trust’s position is that the failings between the missed fracture and Mrs X being bedbound cannot be linked. It says the treatment would have been the same should the fracture have been identified earlier.
54. We have obtained clinical advice in relation to this from the orthopaedic and spinal surgeon adviser as well as the musculoskeletal radiologist adviser.
55. We can see from the clinical notes that following the fracture being identified in the MRI scan the consultant made a referral to the neurosurgeons at Leeds Infirmary for further advice regarding the treatment of Mrs X’s fracture.
56. The records document that on the 10 November 2023, the neurosurgeons advised that given Mrs X’s age, the risks involved in the surgery would outweigh the benefits and so the options for treatment were limited. We can see in the records a discussion was held between Mr X and his sister to discuss this. The risks were explained which would include ‘paralysis’. It was confirmed a ‘pragmatic approach likely best option here-unless family very keen for surgery’.
57. The records document that Mr X wanted time to discuss this with the family. Later the same day, Mr X confirmed the family had agreed not to go ahead with surgery given the risks involved.
58. Therefore, following the fracture being identified in the MRI scan, the agreed treatment was for Mrs X to be discharged home for bed rest for six weeks and then if appropriate, for her to be referred for community therapy. This is documented in Mrs X’s Occupational Therapy Assessment dated 8 November 2023.
59. The records show Mrs X had a pre-existing ‘ankylosed spine’ as well as the identified fracture. This is where the spine becomes inflamed and stiff as detailed in the NHS England guidance named ‘Overview-ankylosed spine’.
60. The orthopaedic and spinal surgeon adviser says extensive research has been completed to understand the best treatment of fractures where a person is suffering with an ankylosed spine.
61. Article named, ‘Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications’ states in the preferred ‘type of treatment’ that ‘bed rest’ is advised.
62. The referenced article also explains that best rest is advised for ‘weeks’. We can see from the records Mrs X was advised bed rest for six weeks following which she was to be reviewed again.
63. Based on the above, we consider there to be no evidence of failings in the Trust’s decision to take a pragmatic approach and advise bed rest. We understand this was a joint decision by professionals and the family to not continue with surgery.
64. The orthopaedic and spinal surgeon adviser tells us that bed rest in these situations is the only alternative, but carries further risks including the risk of reduced mobility. We can also see Mrs X had a pre-existing osteoporosis (therefore had poor bone quality) and Parkinson’s disease which also affects mobility.
65. This is supported by NHS England guidance ‘Overview-Parkinson’s disease’ which says the main symptoms of the disease include ‘slow movement, stiff and inflexible muscles’.
66. Based on the evidence we have seen, we have found failings in the Trust missing the fracture from the initial CT scan. We have found no evidence to suggest that this caused Mrs X’s treatment to be delayed as the same treatment plan would have been followed based on Mrs X’s clinical history.
67. We have also found no evidence to suggest that because of the missed fracture Mrs X has been bedbound since the date of her discharge.
68. We acknowledge that the missed fracture has caused both Mr X and Mrs X distress. We can see the Trust has acknowledged the failings, apologised and explained actions it has completed to ensure learning has been taken from this. We consider these actions to be in line with our Principles for Remedy.
69. We do not consider a financial remedy is appropriate in this case. In deciding this we have reviewed our financial remedy scale. The scale helps us determine financial recommendations for non-financial loss, for example distress.
70. Having carefully considered this, we consider the distress suffered falls under level one of our financial remedy scale. This is because knowing that the fracture was missed has caused a ‘low impact injustice’ such as distress. It was also an isolated incident happening only once. We have found no evidence that this led to a clinical impact or detriment to Mrs X. In such cases, we consider an apology to be appropriate.
71. We can see the Trust has already completed these actions and therefore consider there to be no further actions proposed for the Trust to complete. We consider the distress to already have been remedied.
72. Based on the above, we do not uphold this part of the complaint.
73. In conclusion, we do not uphold this complaint.
74. It is important to acknowledge that we agree failings have happened specifically by the fracture being missed in the initial CT scan. We cannot link this, however, to the claimed impact. We also acknowledge that where we have not identified any indications that something went wrong, it does not detract from Mr and Mrs X’s experience, nor the impact that this has had on them.