A GP practice in the Leeds area

3. Mrs D complains about the treatment and advice she got from the Practice on 6 September 2022 after falling and breaking her jaw.

4. Mrs D says she was not advised to go to A&E, the Practice should have X-rayed her and she should have been given more treatment.

5. Mrs D says she was denied quick treatment and a quick recovery and she was left with no option but to get private advice.

6. Mrs D wants a financial payment.

7. Mrs D fell and hurt her chin, broke her left jaw, and injured her mouth area on 6 September 2022. Mrs D thinks the Practice nurse who saw her should have done more than just glue her chin. She thinks she should have been X-rayed.

8. Nine days later, Mrs D went to a dentist who X-rayed her jaw and found that it was broken. She paid for a private consultation which led to an urgent operation on the NHS leaving her with metal braces for eight weeks and biting issues. Mrs D thinks if she had been referred to a specialist straight away she would have recovered sooner.

12. 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 not seen any signs that something has gone wrong.

X-ray

13. We asked the Practice why it did not X-ray Mrs D. It explained that although it does have access to an X-ray machine, there are limits to what it can be used for. It says it is only able to X-ray minor injuries to limbs. It advised it is unable to X-ray face, back, chest, or pelvic areas. Patients with injuries to these areas, like Mrs D, are advised to go to A&E. The Practice says it gave Mrs D this advice.

14. We asked our adviser if it is unusual for a practice to not have the ability to X-ray a jaw. They said this is not unusual as face, back, chest or pelvic injuries often need more specialised review and treatment. Even if the Practice could do the X-ray, it would still need to refer Mrs D to a service who could treat more complex injuries. But, the Practice does not have the ability to do the type of X-ray Mrs D needed.

15. We have seen no failing in this part of the complaint as we would not expect the Practice to attempt to X-ray a patient in this situation.

A&E

16. Mrs D says she was not advised to go to A&E by the nurse at the Practice.

17. The notes from her visit say Mrs D was, ‘advised to go to A&E department of choice’.

18. Medical notes like these are legal documents and should accurately record any discussions or advice given. The notes say that Mrs D was advised to go A&E and we have no reason to question this evidence.

19. Our adviser said it would be the correct procedure to advise a patient to go to A&E if the patient needed a more thorough examination. This seems to be what Mrs D needed. They said it was not in the remit of the Practice to be able to give a more detailed examination.

20. Mrs D told us many times that she did not want to go to A&E because of the long waiting times to be seen. This suggests that Mrs D was aware that going to A&E was an option for her at that time.

21. The evidence leads us to conclude that the Practice did advise her to go to A&E and this is in in line with NICE guidance.

22. We have seen no failing with this part of the complaint.

Treatment

23. The Practice cleaned Mrs D’s wound, applied medical glue, told her to take paracetamol when necessary and advised her to go to A&E. Apart from the advice on going to A&E, Mrs D does not deny what the nurse did.

24. But, Mrs D thinks the nurse should have done more to treat her injuries. The Practice complaint response says it was happy the treatment it gave to Mrs D was appropriate.

25. We asked our adviser if more should be done by the Practice. Our adviser explained there was no evidence of a life-threatening condition that needed immediate emergency intervention. They said it was appropriate for the nurse to clean the wound, glue the cut, recommend paracetamol and advise Mrs D to go to A&E.

26. This is in line with NICE guidance that says:

‘Refer to A&E if...The expertise to manage the wound is not available in primary care...There is a bony injury or fracture...It is a facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of the lips, nose, or ears.’

27. We know Mrs D went to the Practice after a fall which caused facial lacerations, suspicion (later confirmed) of a possible fracture and which the Practice may not have had the expertise to manage due to its limited resources.

28. It was appropriate to not attempt to manage Mrs D’s injuries beyond basic first aid and assessment. As we now know that Mrs D’s injuries were more serious and she had a fractured jaw, it was correct for the Practice to give her this treatment and recommend that she goes to A&E. While the nurse did not have the benefit of knowing the later diagnosis, it is clear that Mrs D’s facial injuries were significant enough to fit the description in the guidance above.

29. Other NICE guidance says:

‘If a serious or life-threatening condition is suspected following an assessment for red flags, manage appropriately using clinical judgement. Refer people to oral medicine or oral and maxillofacial surgery for specialist investigations and management, depending on clinical judgement, if they have...A history of trauma or fracture to the temporomandibular [jaw] joint’.

30. The guidance gives information on what red flags to look for:

‘Red flags for orofacial pain [pain felt in the mouth, face and jaw] include:...History of recent head or neck trauma.’

31. Mrs D’s case was a red flag because the nurse knew she had just had an accident and injured her face and jaw. Even suspicion of a possible fracture would prompt the nurse to refer her on for specialist investigations. This would then confirm or rule out more serious injuries that the Practice was not able to treat. We have decided that the Practice could not have given any more treatment than it did.

32. The care the Practice gave was appropriate and in line with good practise and relevant guidelines. We have not seen any sign of a failing in this part of the complaint.

33. We understand this may not be the outcome Mrs D wanted but we hope we have clearly explained the reasons for our decision.

34. We are sorry to hear about Mrs D’s injuries and the impact these had on her life. We hope she has now recovered.

1. We have carefully considered Mrs D’s complaint about a GP Practice in the Leeds area (the Practice). We are sorry to learn about the difficult time Mrs D had after her accident and the stress this caused.

2. We have seen no sign that the Practice got anything seriously wrong and have decided not to consider this complaint further. We explain our decision in this statement.