Cambridgeshire and Peterborough NHS Foundation Trust

3. Mrs A complains about aspects of the care and treatment she received from Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) between 20 and 22 December 2021. Specifically, she complains the Trust did not listen to her reports of pain coming from her ankle, which meant she was not assessed or diagnosed correctly. She says the Trust did not diagnose an ankle fracture (fracture to the fibula) and instead treated her for a soft tissue injury.

4. Mrs A says she was immense pain from her ankle and unable to weight bear. She says the pain from the light exercises the Trust told her to do caused great pain and due to her being diabetic type 1 had the potential for consequences with the medication for her diabetes.

5. Mrs A wants an acknowledgment of failings of the Trust and financial remedy for the cost of the X-rays of when she went for a private consultation totalling £400.

6. On 20 December 2021, Mrs A presented at the Minor Injuries Unit (part of the Trust) following a fall down a flight of stairs at her home. After being triaged Mrs A had an X-ray of her lower left leg (tibia/fibula) and told there was no break or fracture and she was treated for soft tissue damage.

7. On the afternoon of 20 December, Mrs A was contacted at home by a nurse from the Trust and was told her X-rays had been reviewed there was a subtle darkening around the middle of her lower leg (the fibula bone) which might indicate a fracture. She was asked to return to the MIU, so the Trust could give her a walking boot to protect the bone. Mrs A declined to return to the Trust because she said she had a boot she could use at home from a previous injury and she already had a walking aid.

8. The Trust told Mrs A the MIU would submit a referral to the fracture clinic for a follow up appointment.

9. On 22 December, the fracture clinic at the Trust reviewed the X-rays which were taken on 20 December and then contacted Mrs A. It told her there was no fracture and discharged her. It advised if she was still struggling to weight bear, she could be reviewed face to face, and it was going to treat the injury as soft tissue damage.

10. On the evening of 22 December Mrs A attended a private hospital which took new Xray’s showing she had a fracture of the fibula (lower leg bone) near to her ankle.

17. Before we decide if we should conduct 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 found any indications that something has gone wrong.

18. On 20 December 2021 Mrs A fell down the stairs at her home and injured her ankle. She went to a Minor injuries unit (MIU) which is part of the Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) for treatment.

19. Mrs A says the Trust did not listen to her when she was describing the pain was coming from her ankle and not her leg. We can appreciate why this would be concerning for her. She told us the Trust completed an X-ray on her lower leg and did not X-ray her ankle. Mrs A says the Trust diagnosed her with a soft tissue injury and gave her exercises to do which could have been detrimental.

20. Mrs A says when the Trust offered her a walking boot, she declined it as she had a protective boot at home due to a previous ankle injury. She told us due to the swelling she was unable to get the boot on her ankle and did not think this was the best treatment for her.

21. Mrs A told us she had private medical insurance (BUPA) and contacted them to get an appointment for a second opinion. She attended an appointment at a private hospital on 22 December where she was assessed and had a X-ray of her ankle which showed she had a fracture to her fibula at the ankle.

22. The Trust says it conducted an investigation and it did not find anything went wrong with Mrs A’s treatment.

23. Mrs A was assessed and treated in the MIU by a nurse practitioner (NP). This is common practice in this type of unit.

24. The NP initially diagnosed Mrs A with a sprain (soft tissue damage) to her ankle, but they could not rule out a fracture. This is because the radiology team was initially unable to identify a fracture from the X-rays.

25. Mrs A was discharged with safety advice to return if her injury worsened.

26. A radiographer re-reviewed the X-rays later that day and identified Mrs A had a subtle corneal lucency (a corneal lucency is a darker area on the X-ray) at the midshaft of the fibula.

27. The records show the Trust contacted her and asked if she could return to the department to be given a walking boot to protect the leg/ankle. The Trust advised it was also referring her to the fracture clinic and Mrs A was given light exercises.

28. We know Mrs A did not collect the walking boot as she said she had a boot at home and she had a walking aid at home.

29. We have seen Mrs A’s treatment records and saw she was examined in the MIU by a Nurse Practitioner.

30. NICE guidance says clinicians should ask how the injury happened, note any previous injuries, touch and examine the affected area, and assess the patient’s movement noting the symptoms and their severity. The guidelines say clinicians should examine patients for possible complications.

31. The records show the NP took all the details as required by the NICE guidance.

32. It is documented Mrs A was crying in pain upon light touch to the middle of her lower leg and tender near her ankle. There was no bony tenderness noted near Mrs A’s knee or in the bones in her foot. The NP examined Mrs A’s toes and noted no pain reported. All pulses were checked and intact and Mrs A’s blood flow to her foot and toes was checked and documented. Mrs A’s notes record there was pain in her ankle and she had full range of movement.

33. The Trust says the ‘Look, Feel, Move’ method was used when Mrs A was examined. This method is not specifically named and referenced in the NICE guidance, but ‘Look, Feel, Move’ employs and incorporate the assessment requirements as contained in the NICE guidance. This means if clinicians follow the ‘look, feel, move’ while examining patients, clinicians will satisfy the examination requirements in the NICE guidance.

34. Our nursing adviser confirmed the ‘Look, Feel, Move’ method of assessment is taught as part of clinical examination skills.

35. We have not found anything went wrong with the assessment conducted by the NP at the Trust.

36. Mrs A says she was diagnosed privately with a shear fracture which could have required an operation to fix. We understand Mrs A was treated with an air cast boot (diabetic specification) and we were pleased to see Mrs A did not need an operation.

37. Following the initial examination, the NP sent Mrs A for X-ray’s. The NICE guidance says a person should be given an X-ray following an ankle injury if they cannot bear weight on that ankle or cannot manage four steps or if bony tenderness is present. We understand Mrs A met the requirements for X-rays. Our nursing adviser also confirmed X-rays were clinically indicated.

38. We saw the NP ordered X-rays of Mrs A’s lower leg, taken from the front and back, and from the side, along with a knee view. This means Mrs A’s whole lower leg was X-rayed.

39. Our nursing adviser explained the tibia and fibula are attached by soft tissue at both the top and bottom, and so an X-ray of both is entirely appropriate.

40. To understand if the X-rays were correctly read, we spoke with our radiology adviser.

41. Our radiology adviser looked at the first X-ray taken on 20 December by the Trust and the second X-ray taken by the private hospital on the 22 December 2021.

42. Our radiology adviser confirmed the fracture at the ankle is visible on the second X-ray taken on 22 December by the private hospital. Our radiology adviser said an obvious fracture is not present on the Trust’s X-rays. They told us a subtle oblique (diagonal) line can be seen on the Trust’s X-ray which does not have the appearance of a fracture, as lines such as these can be caused by blood vessels.

43. Our radiology adviser explained there is no break or gap in the cortex. The cortex of the bone is the hard outer layer and a gap in the cortex is what radiologists look for when diagnosing a fracture.

44. Our radiology adviser explained an X-ray does not always exclude a fracture. If a patient still has pain after a few days from the initial incident X-rays should be repeated. They said it is common for some fractures not to be identified in the first instance because there is no gap in the cortex. After a few days and during the healing process, the break in the cortex of the bone becomes more visible on X-ray.

45. Our radiology adviser explained in the second X-ray the fracture presentation is more obvious because the gap in the cortex is visible, but there is not a gap in the original X-ray.

46. Mrs A says the break was a bad shear break which could have severed a nerve. We understand why Mrs A would be worried by this, particularly if she could have suffered nerve damage. We were pleased to learn she did not suffer nerve damage.

47. We have not found any evidence of failings in the reading of the X-ray at the Trust. We consider the fracture was not clearly visible on the X-rays taken by the Trust on 20 December. We think it is likely the fracture became more obvious by 22 December which is why it showed up more clearly in the X-rays taken at the private hospital.

48. We hope this reassures Mrs A her ankle and the site of her fracture were X-rayed correctly and reviewed by the Trust on 20 December. We will not take further action on this part of the complaint as we have seen no indication anything went seriously wrong.

Treatment

49. Mrs A says she was discharged by the Trust and given exercises to do which she says could have damaged her leg. Mrs A told us she did not complete the exercises. We recognise she is worried about what might have happened had she done so.

50. The Trust was unable to identify a fracture from the X-rays taken on 20 December therefore it discharged her with the following advice:

• ‘Rest, ice and elevation for minimum of 48 hours, continue with regular prescribed analgesia • Regular gentle movement, ankle rehab exercises described, written advice sheet given as well as physio self referral form to use if needed • Advised possible 4-6 week full recovery time, return/ seek review with any further concerns’.

51. Later on the 20 December Mrs A was contacted by the MIU and advised her leg would be treated as a fracture and for her to use a boot to support the lower leg and help it to heal. As explained, Mrs A told the caller she had a boot she could use at home and a walking aid and did not go back to the MIU.

52. On the 22 December the fracture clinic called Mrs A and told her she did not have a fracture but if she was still struggling to weight bear she could be reviewed face to face.

53. Following this telephone call Mrs A thought her leg was broken and went to a private hospital for treatment.

54. In the Management section of the NICE guidance it explains what a patient should be advised to do after a suspected sprain or strain. The NICE guidance says rest, ice and elevation are recommended for the first 48-72 hours. It then recommends exercises once pain reduces. We consider the Trust’s advice to Mrs A on discharge was in line with guidance as it had not found a fracture and had diagnosed her with a soft tissue injury.

55. Between 20 December and the 22 December, after the X-ray’s were reviewed by the fracture clinic, the Trust’s advice was for Mrs A not to do exercises, as she was told to rest for two days and was advised by the fracture clinic her injury was to be treated as a fracture.

56. We know Mrs A thought she had a fracture and this is why she went to a private hospital. She was given advice to return to the Trust if her symptoms persisted or worsened and she would be re assessed. Instead, Mrs A chose to go to a private hospital and did not continue her treatment with the Trust.

57. We have not seen anything went wrong with the treatment advice the Trust gave Mrs A when discharging her from the MIU on 20 December 2021. We appreciate Mrs A is concerned about how serious her injury could have become and we are pleased to hear she is recovering well.

58. We thank her for sharing details of her experience with us.

1. We have carefully considered Mrs A’s complaint about Cambridgeshire and Peterborough NHS Foundation Trust (the Trust).

2. We have seen no indication that anything went seriously wrong with the treatment which was provided by the Trust. We appreciate Mrs A’s concern she could have suffered a more serious injury and we were pleased to see this did not happen.