An independent provider in the Hillingdon area

5. Ms O has complained about the Provider’s care in October 2020. Ms O says:

• she told the nurse it was her left knee that was injured but the nurse failed to do an adequate examination • the Provider did not do appropriate investigations into her injury and discharged Ms O when her care should have been escalated • the emergency nurse practitioner did not explain the need of the cricket splint and gave crutches that were too big for Ms O’s needs.

6. Ms O says these events caused her emotional and physical distress including extreme pain. She says she has been left distressed, had to fight to get treatment and lost income. She told us the nurse did not believe her statements about the nature of her injury, which was distressing.

7. Ms O wants a financial payment. She has also requested a letter of apology.

8. On 24 October 2020 an ambulance took Ms O to an urgent care centre that is part of the Provider. She had fallen while walking and was in extreme pain.

9. On arrival, an emergency nurse practitioner reviewed Ms O. The Provider completed an X-ray. This found no broken bones but noted a floating bone. A floating bone is a fragment of bone not connected to another bone.

10. The emergency nurse practitioner put a cricket splint on Ms O’s left leg. They also gave Ms O crutches. The emergency nurse practitioner booked Ms O an appointment at an urgent virtual fracture clinic (part of another NHS organisation). The fracture clinic was to contact her within 48 hours.

11. The fracture clinic spoke to Ms O 36 hours later. An appointment at a local NHS hospital (not part of the Provider) was organised for 2 November.

12. At that appointment, an ultrasound confirmed Ms O had ruptured her quadricep tendon in her left leg. The hospital decided Ms O needed immediate surgery. Due to delays, the hospital only completed the surgery on 6 November. The hospital discharged her on 12 November. The hospital’s orthopaedics department discharged her from its care on 7 January 2021.

Examination

16. Ms O told us the emergency nurse practitioner who reviewed her repeatedly asked her to lift her left leg, even after she told them she was unable to. She said the practitioner did not believe her when she said it was her left knee that was injured.

17. Ms O told us the practitioner had her get up from a sitting position without support. She said they told her she had to weight bear on her left leg which caused agonising pain and led her to scream.

18. The Provider said the practitioner did an examination, they compared both knees and found Ms O’s left knee to be slightly more swollen than her right.

19. The Provider said the practitioner requested an X-ray, which found a small chip of floating bone. Based on her presentation, the practitioner decided to immobilise Ms O’s knee in a cricket splint and provided crutches. The practitioner also completed an urgent virtual fracture clinic referral. During the clinic a specialist would decide on the next steps.

20. The Provider apologised that Ms O’s treatment fell below acceptable standards. It also apologised if the practitioner did not communicate the need to fully examine other areas for damage.

21. NICE guidance says if there is a history of trauma (such as a fall), clinicians must do an assessment for injuries including fracture, tendon rupture or ligament tears. When examining patients with knee pain, the NICE guidance says clinicians should follow the look, feel, move orthopaedic model. It suggests, when there has been a history of trauma, to complete the following:

• use the Ottawa knee rules (detail about these rules can be found in paragraph 33 below) in people over two years of age to decide whether an X-ray is needed to assess for fracture • ask the person to do an active straight leg raise while lying down • assess for a gap in the quadriceps or patellar tendon (tendons connecting to the patella or kneecap bone) • check the position of the patella for deformity • assess for ligament tears and laxity (looseness).

22. The triaging nurse who first saw Ms O wrote she was able to weight bear with a limp, with pain to her right knee. Our nursing adviser said it was unclear whether this history came from Ms O or the paramedics, but it includes an error about which knee was affected. The practitioner’s notes recorded the detail above again, without correcting the affected knee.

23. Our nursing adviser said clinicians should record the findings of the look, feel and move examination in the notes. They said there should be a systematic approach to show a logical and structured examination. They said there was some evidence of this structure in the documentation but some information was missing.

24. Our nursing adviser told us there was no documentation of the soft tissues, including the quadriceps and patella tendons. They said the practitioner had clearly noted that the patient could not straight leg raise and they had commented on the degree of flexion (bending the knee) and extension (straightening the knee).

25. But there was no documentation about any examination of the integrity of the soft tissues. There was no testing of soft tissues by stress test, a test for laxity or increase in pain.

26. There was also no comment on active, passive and resisted movements of the knee and no note on the ability to weight bear. Active movements are those completed using the patient’s own muscle strength without assistance. Passive movement is when the practitioner moves the patient’s knee while the patient’s muscles remain relaxed. Resisted movements are when patients use their muscles against resistance applied by the practitioner.

27. Our nursing adviser told us the ability to weight bear is a key assessment in the management of lower limb injuries. They told us if it is not assessed there can be no accurate assessment of the injury and its severity.

28. Ms O told us the practitioner did ask her to stand and weight bear. But, the practitioner’s examination does not record an assessment of Ms O’s mobility, whether walking, limping or her inability to bear weight on the affected limb.

29. This shows the examination was not in line with the NICE guidance. We considered whether the Provider’s failure to complete an examination in line with the NICE guidelines had an impact on Ms O in the ‘impact’ section below.

Further investigations

30. Ms O told us the Provider should have completed more investigations into her knee injury before discharge.

31. The Provider said the urgent care centre had no facilities to provide ultrasound scans to help diagnose the more uncommon injuries not seen by X-ray. It said it expected its clinicians to immobilise joints and make the appropriate referrals to the specialist orthopaedic team, who are more able to manage a wider range of injury.

32. The orthopaedic team (part of another NHS organisation) contacted Ms O within 36 hours of her injury. She reported to it that she could fully weight bear but could not straight leg raise. Based on this history, the orthopaedic team provided Ms O with an orthopaedic appointment for 2 November 2020.

33. NICE guidance recommends the use of Ottawa knee rules to decide whether clinicians should do an X-ray.

34. The AMA journal details the Ottawa knee rules. These rules say an X-ray is needed only in patients who have an acute knee injury and meet one or more of the following: • aged 55 years or older • tenderness at head of fibula (calf bone) • isolated tenderness of patella • inability to flex the knee greater than 90 degrees • inability to bear weight both immediately and in the emergency department.

35. The Clinical guidance says, ‘an injury which separates the extensor mechanism will leave the patient unable to achieve a straight leg raise because of the loss of the connection between quadriceps and the tibia [shin bone]. Such an injury will require surgery.’ The extensor mechanism consists of a chain of anatomical structures including the quad muscle and kneecap that work together to straighten the knee.

36. The NMC guidance says nurses should recognise and work within the limits of their competence and make a timely referral to another practitioner when any action is needed.

37. Our nursing adviser said Ms O met the Ottawa knee rules criteria for an X-ray. This is because Ms O was over 55 at the time of the injury and could not weight bear during the examination. The Provider completed this X-ray on the same day. Our nursing adviser told us in an urgent care centre, it is unlikely that the clinicians had access to any other type of investigation other than X-ray for a suspected leg injury.

38. The X-ray showed a bony fragment above the knee cap. The practitioner reviewed the Xray and recorded ‘no bony injury noted, small avulsion [part of a bone had become detached] noted, rounded body.’

39. Our nursing adviser said this comment was contradictory because an avulsion is likely to suggest an avulsion fracture or bony injury. An avulsion fracture happens when an injury pulls off a ligament, tendon or muscle attachment site from the bone, usually taking a fragment of bone with it.

40. Our nursing adviser said if clinicians suspect a more severe injury, they should discuss the injury with the appropriate specialist. The specialist team would then decide whether further action was needed. This might include completing more investigations like an ultrasound. The specialist team would also decide whether a specialist should review the patient urgently or at a regular outpatient appointment.

41. Our nursing adviser told us Ms O needed at least a specialist orthopaedic opinion before she was discharged. They said she could not straight leg raise so had lost her extensor mechanism.

42. In summary Ms O had knee trauma, an X-ray showed a piece of floating bone in the knee and she was unable to raise her leg up off the bed. Our nursing adviser said these factors meant the practitioner should have considered Ms O had an avulsion fracture, an injury that needed escalation.

43. We can see the practitioner did arrange a virtual appointment and Ms O was contacted by another NHS organisation within 36 hours. But, as we seen there is evidence Ms O had a severe injury and her care should have been escalated immediately.

44. The failure of the practitioner to escalate Ms O’s care means they did not act in line with the NMC guidance. The practitioner’s actions do not seem to consider the Clinical guidance that says an injury that causes the loss of the extensor mechanism will need surgery.

45. We have considered how this failing affected Ms O in the ‘impact’ section below.

Cricket splint and crutches

46. Ms O told us the practitioner did not explain that she would have to wear the cricket splint continuously. She says the practitioner also gave her the wrong size crutches, which the hospital had to replace when she attended for her operation.

47. The Provider said the practitioner’s normal practice when providing a cricket splint is to tell a patient they should continue to wear the splint until seen at the fracture clinic. It apologised if the practitioner did not give Ms O the necessary information.

48. The Provider said it provides crutches of one size, which can be adjusted up and down to match a patient’s height. It apologised if the practitioner did not adjust the crutches.

49. Clinical guidance says clinicians should provide splints and crutches to patients with knee injuries. RCN guidance says nurses should be competent in giving the right size crutches. NMC guidance says nurses should practice effectively and advise on treatment to the best of their abilities.

50. Our nursing adviser said Ms O met the criteria for the need for a cricket splint and crutches in line with the Clinical guidance. This was due to her knee injury.

51. The records do not include any mention of the use of the splint, but we know one was given to Ms O. There is no evidence to show the practitioner explained to Ms O how the splint should be used.

52. The practitioner recorded in the medical notes that crutches were given to Ms O but there are no notes to suggest there was a discussion with Ms O about how to use the crutches.

53. Our nursing adviser said in these circumstances the practitioner should discuss with the patient whether they could partially weight bear or whether they should avoid putting any weight on the injured leg. The failure to do this meant the practitioner did not follow NMC guidance.

54. We can see the practitioner provided crutches and a splint in line with Clinical guidance. But, there is evidence the practitioner failed to provide an explanation about the use of crutches and the splint in line with nursing guidance. We looked at whether the failings we have found had an impact on Ms O below.

Impact

55. Ms O told us these events left her in emotional and physical distress. She has described being in extreme pain during and after the examination. She also feels she had to fight to get treatment. Ms O has asked for a financial payment for her lost income. She has suggested she lost an opportunity to work for six weeks.

56. We have found the Provider failed to follow guidance around finding a serious knee injury and failed to escalate care before discharging Ms O. We have also seen the practitioner failed to explain how the crutches and splint should be used.

57. The decision by the practitioner to not escalate Ms O’s treatment immediately meant there was a delay before the orthopaedic team considered her case. Our orthopaedic adviser said that if specialists had seen Ms O that day, it was possible surgery could have been completed earlier.

58. We know Ms O was seen in a virtual clinic run within two days of being seen by The Provider. At that time, the virtual clinic did not refer her for immediate surgery. It instead arranged an orthotic appointment at an NHS hospital on 2 November 2020 (orthotics are devices prescribed by a doctor to correct foot deformities, provide support and improve function). Once at the hospital, clinicians decided she needed surgery to fix her ruptured quadriceps. Surgery did not go ahead until four days later.

59. Our orthopaedic adviser said it is unlikely the delay of up to 36 hours in Ms O being seen by the orthopaedic team caused any long-term physiological effects.

60. The Quadriceps paper says it is recommended to complete surgery as soon as possible after diagnosis of quadriceps tendon rupture, within 48 to 72 hours if possible. But, it also says surgery within two weeks would be acceptable in terms of an ability to achieve satisfactory primary repair and outcome. Records show the hospital completed Ms O’s surgery within two weeks.

61. The medical records from Ms O’s orthopaedic appointments after the operation in December and January show her range of motion was improving. The records also suggest her tendon had healed well. The hospital discharged her from orthopaedics in January. She continued with physiotherapy.

62. There is no way of us knowing whether surgery could have been completed earlier if the Provider had not caused a delay. What we can say is that, regardless of the delay, Ms O had her operation within an acceptable timescale to allow for a good outcome.

63. We accept there was a period of time when Ms O was unable to work. But, we have found this was due to the accident and not to the failings by the Provider. We cannot say the Provider’s delay caused Ms O a delay in getting back to work. We have not recommended any financial payment for a lost opportunity to work.

64. In our view, the failings of the Provider to escalate Ms O’s care immediately caused her 36 hours of emotional distress and physical pain. She would not have had this to the extent she did, if this failing had not happened.

65. Our orthopaedic adviser said the use of a cricket pad splint is to only provide temporary support to the knee and leg while waiting for further review and treatment. They said it was unlikely that failure to explain how to use the splint caused any significant damage, other than causing some added pain due to lack of support.

66. Our orthopaedic adviser said it was unlikely that failure to provide properly sized crutches caused any significant impact other than some lack of support and possible increased pain as a result.

67. In summary, we can say the Provider’s failings in these areas caused Ms O short-term distress and added pain. We cannot say that this led to a loss of income because we cannot see that the delay caused by the failing had any impact on Ms O’s ability to work.

68. We appreciate Ms O feels she had to fight to get treatment which understandably caused her distress. We understand how distressing these events must have been. Our recommendations to the Provider are below.

1. We would like to thank Ms O for bringing this complaint to us. We understand how hard it must have been for her to revisit these events.

2. We have found a healthcare provider in the Hillingdon area (the Provider) failed to follow guidance around the examination of Ms O and it failed to immediately escalate her care. We also found it did not follow guidance around explaining the use of a cricket splint (fabric brace to support an injury) or around the use of appropriately sized crutches. We found these failings caused Ms O distress and added pain.

3. We recommend the Provider apologises to Ms O. This apology should cover the distress caused to her for delaying the escalation of her care. Finally, we recommend the Provider pays her £300 in recognition of the distress and pain these events caused.

4. We have upheld this complaint.