A medical practice in the Greater Manchester area

6. Mrs O says the practice misdiagnosed her son’s broken leg on 25 October. She says the clinician ordered an X-ray of his right foot only, despite his leg being bent. She says a full X-ray of his leg should have been taken.

7. Mrs O also complains about the handling of her complaint. She says she was promised weekly updates that did not always happen and the practice took weeks to respond to her complaint.

8. Mrs O says as her son had not improved, she took him to hospital on 28 October where he was diagnosed with a broken right tibia. She says her son was left in agony for two days and the events extended his recovery by four weeks.

9. She says her son had to learn to trust his leg again. Mrs O also says he missed out on starting nursery for 12 weeks and is now behind in his education. She says the whole ordeal and the practice’s handling of her complaint caused her distress.

10. Mrs O is seeking an acknowledgement of failings and a financial remedy as an outcome to the complaint.

11. On 25 October, Mrs O took her son to the Urgent Care Centre (UCC) at the practice. He was two years old at the time. An X-ray of his right foot was taken, and he was diagnosed as having a sprain.

12. Mrs O attended the UCC with her son again on 28 October. Following an examination and X-ray of his full leg, he was diagnosed with a broken leg.

13. On 9 November he had a cast put on the leg at a nearby hospital trust’s fracture clinic.

18. Mrs O says the practice misdiagnosed her son’s leg injury. She says an X-ray of his right foot was requested despite his leg being bent and says a full X-ray of his leg should have been taken.

19. We asked our ED adviser if Mrs O’s son received the correct care on his attendance to the UCC on 25 October.

20. Mrs O’s son attended the UCC following an unwitnessed injury to his right lower limb. The records document that both his parents and the triage nurse saw that he was unable to weight bear after the injury.

21. The triage nurse documented that Mrs O had seen a red mark on her son’s right toe though the triage nurse was not able to see this. The triage nurse noted that there was no swelling or bony tenderness to the foot.

22. The notes documented by the treating clinician are brief. They document that Mrs O’s son’s foot was swollen but neurovascularly (relating to the nerves and blood vessels) intact. No other examination is documented in the notes.

23. In response to the complaint, the clinician gave a statement. They say they carried out a thorough examination excluding any other injury and say Mrs O’s son was fully weight bearing at the time of the examination. These findings have not been recorded in the contemporary clinical notes at the time Mrs O’s son was seen.

24. A child of Mrs O’s son’s age is unable to give a clear history of events. We would therefore expect a thorough examination to be completed and for a clinician to document their findings at, or promptly after an examination.

25. GMC states that ‘clinical records should be clear, accurate and legible and all relevant clinical findings should be recorded.’

26. The contemporary medical notes documented at the time, do not detail a thorough examination and the findings described in the clinician’s documentation are not consistent with notes documented by the triage nurse’s or Mr and Mrs O’s version of events.

27. We asked our ED adviser if an X-ray of Mrs O’s son leg should have been requested on 25 October.

28. Young children can find it difficult to localise the site of an injury. It is therefore, often necessary to X-ray an entire limb to ensure significant injuries are not missed.

29. Spiral fractures (bone fractures which occur when a long bone is broken by a twisting force) of the tibia (shin bone), also known as ‘toddler’s fractures’, are common. Guidance from the BMJ suggests that toddler’s fractures should be investigated with an X-ray in infants when they present difficulties in weight bearing.

30. Similarly, NICE guidance on acute childhood limp says, ‘if there is any history of trauma or focal bony tenderness on examination, an X-ray should be arranged.’

31. Mrs O’s son’s tibia fracture was visible in the X-ray of his foot. The radiology report was recorded at 9:37pm on 25 October. The report mentions the presence of a possible fracture in the tibia.

32. Mrs O’s son was then assessed by the clinician at 11.11pm once they had sight of the radiology report. Given the radiology report findings, the treating clinician should have requested for further X-rays of Mrs O’s son’s lower leg to confirm if his tibia was fractured.

33. We have found that there was a missed opportunity to diagnose Mrs O’s son’s tibia fracture earlier than it was. We recognise this was an upsetting time for Mr and Mrs O, as their son was in pain, and this caused them distress at an already difficult time. Guidance says that fractures in children should be investigated with an X-ray if there is a history of injury or trauma. We have found that a full leg X-ray should, therefore have been requested for Mrs O’s son’s attendance to the UCC on 25 October, given the radiology report of his foot, his age and presenting condition. This is a failing.

Impact

34. Mrs O says her son was in pain and did not move for two days. She says on his attendance to the UCC again on 28 October, he was diagnosed with a broken leg.

35. She says the clinician who saw her son, said they were able to see how bent and broken his leg was just by looking at it, and therefore requested an X-ray of his leg.

36. She says they also told her that the misdiagnosis extended his recovery by a few weeks as it was left untreated for two to three days. She says her son was in a back slab cast until 9 November where a full leg cast was then put on.

37. She says her son’s recovery was extended by an extra four weeks and he had to learn to trust his leg again before being able to walk.

38. We asked our ED adviser if the delay in diagnosing Mrs O’s son’s tibia fracture had an impact on him.

39. Our ED adviser says that although the fracture was missed on 25 October, not diagnosing the fracture that day would not have had a significant impact on Mrs O’s son. This type of fracture is common in children of Mrs O’s son’s age. It is a stable fracture that heals well, almost without exception.

40. Guidance from the Royal Children’s hospital of Melbourne on the management of tibia fractures states to initially support the fracture with a back-slab of plaster, and then a full plaster cast. A child can partially weight-bear while in the cast and the total time the limb would remain in plaster is usually around four weeks. Similar guidance is noted in a published study on the management of toddler’s fractures.

41. Mrs O’s son’s records from the orthopaedic team confirm that the fracture had not moved given the X-ray taken on his attendance to the UCC on 28 October.

42. We do not dispute what Mrs O was told on her attendance to the UCC on 28 October with regards to her son’s extended recovery. We have seen no evidence to suggest that the delay in the fracture being diagnosed, led to prolonged or more invasive treatment.

43. We looked at a published study on the management of toddler's fractures in the paediatric ED.

44. The results from this study found that when this type of fracture was managed without support from a plaster-cast, a child recovered with full function in the injured limb more quickly without any negative effects. Consequently, a delay of two or three days in Mrs O’s son being diagnosed with the fracture would not have prolonged his recovery.

45. Mrs O says her son was unable to go to nursery for 12 weeks and is now behind in his education.

46. We recognise that the events may have delayed Mrs O’s son in being able to start nursery any earlier than he could. However, even if the fracture had been diagnosed two days earlier, this would have meant possible time away from nursery.

47. Nursery is optional and it is not mandatory for children. It is aimed at children in the year before joining school. Mrs O’s son was two years old at the time of the events. We cannot say that the events delayed his education as he had not reached the age where he would be expected to receive full time, mandatory education.

48. Mrs O says the events caused her and her husband, distress. We acknowledge that the events caused Mrs O and her husband distress at an already difficult time. Seeing your child in pain is worrying. Mrs O’s son was in pain, and this may have caused him some difficulty in being able to mobilise. We can link this distress to the failing we have found.

49. In response to Mrs O’s complaint, the practice acknowledged that the clinician’s documentation of her son’s symptoms and the assessment they undertook fell below the standard that it would expect. They said the clinician should have arranged for her son to have a full leg X-ray as opposed to an X-ray of his foot only.

50. The practice told us that the complaint was discussed with the practice’s medical director, and a meeting was held with the clinician who treated Mrs O’s son. It was agreed that the practice’s medical clinical lead at the UCC would provide enhanced clinical supervision and the treating clinician would also be subject to increased monitoring. We consider the actions the practice have put in place, are enough to prevent a recurrence.

51. The practice acknowledged the distress the events caused Mr and Mrs O. It offered a financial remedy, which Mr and Mrs O did not accept.

52. The failings we have found mean Mr and Mrs O experienced distress seeing their son in pain, until he was seen at the UCC on 28 October. We think the distress they experienced during this time was unnecessary. We have made a recommendation to remedy the distress the events caused Mr and Mrs O.

Complaint handling

53. Mrs O says she was promised weekly updates that did not always happen and says the practice took weeks to respond to her complaint. She says she was told that her complaint would be resolved by 5 January.

54. The Ombudsman’s Principles for Good Complaint Handling (our Principles) say public bodies should do the following:

· Deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies.

· Acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply. Public bodies should keep the complainant regularly informed about progress and the reasons for any delays and provide a point of contact throughout the course of the complaint.

55. Mrs O raised a complaint on 14 November.

56. The practice discussed the complaint with Mrs O on 20 November. It acknowledged the complaint same day. The acknowledgement letter notes 5 January as the date Mrs O should have received a response to her complaint by. The letter notes that if for any reason, the practice was unable to provide her with a response by this date, that it would let her know.

57. The practice sent Mrs O an update on 4 January. The letter notes that there had been a delay with the investigation as there was a delay in them receiving a response from the clinician who treated her son. The letter notes that the practice expected to respond by 5 February.

58. On 13 January, the practice spoke to Mrs O. She was informed that its clinician was out of the country until 24 January and that it would update her on 28 January.

59. A further update was given to Mrs O on the phone slightly earlier than planned, on 25 January.

60. The practice spoke to Mrs O on 3 February. It said it was still waiting for the treating clinician’s statement, and that it would contact her when it had received this.

61. A further update was given on the phone on 5 February. The practice said it received the treating clinician’s statement and the statement would be sent to an adviser for a review.

62. The notes document that the practice told Mrs O it would get its response drafted as soon as possible and Mrs O was happy with the update. A date for a further response or update was not given.

63. On 22 February, Mrs O emailed the practice requesting an update and response with regards to a settlement by 28 February.

64. The practice spoke to Mrs O on 25 February. It said that on review of the clinician’s statement, its adviser needed further information. She was advised that a panel would need to review her request for compensation as the complaint was upheld, and that this could take some time. The call notes state that at this point, Mrs O requested to be updated weekly. The call notes document that Mrs O would be updated after the practice’s complaints review on a Friday.

65. As agreed, the practice called Mrs O with an update a day earlier than planned, on 4 March. It said it was still waiting for feedback from its adviser. The call notes document that Mrs O was very happy with the update and understood, that this would take time.

66. Mrs O was given a further update on 12 March. The practice explained that the complaint was with the medical director for consideration.

67. An attempt was made to call Mrs O on 19 March and tell her that the response was being finalised, but Mrs O did not answer. The practice’s response was sent to Mrs O the same day.

68. In its acknowledgement letter of 20 November, update letter of 4 January, and call on 13 January, the practice gave Mrs O dates it expected to respond to her complaint by or for a further update. Our principles say that ‘public bodies should keep the complainant regularly informed about progress and the reasons for any delays and provide a point of contact throughout the course of the complaint.’

69. Ideally, the practice should have given Mrs O a new target date to expect a response or update when it spoke to her on 5 February. This could have prevented Mrs O from chasing the practice on 22 February.

70. When the practice next spoke to Mrs O on 25 February, it explained the reason for the delay, and it seems it was waiting its adviser to review the treating clinician’s statement. It is therefore possible, the practice did not know when it would be able to get its response drafted at the time it spoke to Mrs O on 5 February.

71. Although it was not an ideal situation, we think the practice updated Mrs O as best it could.

72. Mrs O says she was promised weekly updates and although she received this on some occasions, they eventually stopped. We do not dispute Mrs O’s version of events and what she says she was told with regards to the frequency of updates. We have seen no evidence of weekly updates being agreed until she requested this during a call on 25 February. We have seen evidence that the practice provided Mrs O with weekly updates as agreed on 25 February.

73. We acknowledge the complaints process took some time and recognise this can be frustrating and stressful for a complainant.

74. Delays to complaint responses can happen for different reasons and sometimes we cannot see the delays are due to service failure and maladministration. For us to find a failing, we would expect to see actions that fell far short of what we set out in our principles.

75. Although the process took some time, we have not seen any evidence of a significant service failure that led to the delay. We have therefore, found no failings in way the practice handled Mrs O’s complaint.

1. Mrs O complains about a medical practice in the Greater Manchester area (the practice) should have requested a full leg X-ray for her son as opposed to an X-ray of his foot only. We have found that a full leg X-ray should have been requested given the radiology report of Mrs O son’s foot, his age and presenting condition.

2. We have not found the events to have led to an impact on Mrs O’s son. We have seen no evidence to suggest that the delay in his fracture being diagnosed, led to prolonged or more invasive treatment, or extended his recovery.

3. The practice acknowledged that the treating clinician’s assessment of Mrs O’s son was below the standard it expected. It also acknowledged that its clinician should have arranged a full leg X-ray. It apologised and has taken appropriate action following its investigation. We consider this is enough to prevent a recurrence of the same incident. It offered a financial remedy for the distress the events caused Mr and Mrs O, which they did not accept.

4. As parents, we understand how distressing it would have been for Mr and Mrs O to see their son in pain. Our decision is to therefore, partly uphold the complaint. The practice should pay Mr and Mrs O a financial remedy of £150 to recognise the distress they experienced.

5. We have not found any failings in the handling of Mrs O’s complaint. We go onto explain the reasons for our decision.