A practice in the Wiltshire area

The Trust

5. Mr O complains about the care the Trust provided on 21 December 2023. Specifically, he complains it did not identify he had multiple rib and sternum (the long flat bone located in the central part of the chest) fractures, and did not provide antibiotics to prevent him developing an infection.

6. He says this left him in pain and allowed him to develop a hip infection which meant he needed an operation. Mr O explains this impacted him financially as he was unable to begin a job.

7. Mr O also complains about the way the Trust communicated with his family during the period of complaint. He says staff repeatedly misinformed his family about the extent of his injuries. He told us this caused tension in his family and his relationship broke down.

The Practice

8. Mr O complains about care the Practice provided on 2 January and 11 January 2024. He says it did not identify that his injuries needed further investigation or provide medication to treat his pain and infection.

9. He is concerned the Practice’s actions contributed to the delay in clinicians identifying the extent of his injuries. He considers it missed opportunities to manage his pain and prevent his infection from worsening.

10. Mr O would like both organisations to apologise for what went wrong and pay a financial remedy.

What follows is a summary of events. We have not included all the details as all parties are aware of this.

11. On 21 December 2023 Mr O attended hospital after a fall. The rapid assessment team carried out a computed tomography scan (also known as a CT scan, a test that takes detailed pictures of the inside of the body) of his chest and abdomen, which radiology reported as showing no signs of fractures. A rapid assessment doctor diagnosed Mr O with a chest injury and discharged him with morphine for his pain.

12. On 2 January 2024 Mr O had a GP appointment. The GP examined him and noted his recent fall alongside the CT scan report. The GP discussed pain relief and reassured him his observations were normal.

13. On 11 January Mr O contacted the Practice again as he felt he had an infection. A GP examined him, noted no signs of infection and concluded that he likely had musculoskeletal chest pain. The GP prescribed diazepam to help with muscle spasms and increased his existing pain relief prescription. They recommended Mr O contact the Practice again if he developed chest infection symptoms or still had chest pain in two to three weeks.

14. On 12 January Mr O called NHS 111 as his right hip had collapsed and he was unable to get up. NHS 111 staff called an ambulance and paramedics took him to hospital.

15. On 13 January emergency department staff at the Trust carried out a CT scan which showed sternum and rib fractures. Staff reviewed scans from 21 December and noted that three rib fractures were visible, but radiology staff had not reported these. The same day Mr O had a CT of his right hip which showed no abnormalities.

16. On 14 January a consultant reviewed Mr O and noted he had multiple rib fractures and a chest infection.

17. Mr O remained in hospital until 6 February. During this time staff noted an ultrasound showed signs of infection in his existing hip replacement. Orthopaedic staff carried out surgery to remove and replace this. Upon discharge the Trust wrote to Mr O’s GP advising he would need to continue taking oral antibiotics for ten weeks after his operation.

The Trust

Investigation and treatment of rib fractures

23. Mr O attended the emergency department on 21 December 2023 after falling down the stairs. He complains the Trust did not identify multiple rib and sternum fractures. He considers staff should have prescribed antibiotics to prevent him developing an infection.

24. In its response to the complaint, the Trust acknowledged staff did not identify Mr R’s fractured ribs. It apologised for this, and the impact Mr R experienced. It explained he would not have received any difference in treatment had staff identified the fractures in December.

25. Our internal adviser explained there are no national guidelines for doctors to follow when investigating potential rib fractures in hospital. In lieu of this we refer to GMC’s Good medical practice. This says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.

26. This guidance explains doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs.

27. Our internal adviser confirmed that doctors use CT scanning to identify rib fractures, and we can see staff performed a CT scan of Mr O’s chest and abdomen on 21 December 2023. The Trust provided suitable investigation of Mr O’s injuries. It did not identify fractures on the scan results.

28. Mr O had a second CT scan on 13 January. This showed the presence of multiple rib and sternum fractures. An emergency department doctor reviewed the CT scan from 21 December and identified that three rib fractures were visible which a radiologist had missed.

29. Mr O says doctors should have identified all rib and sternum fractures on 21 December 2023. We have not seen evidence to support this view as clinical records clearly state only three were present on the initial scan and significantly more were present on the second scan.

30. He considers the Trust should have provided him with different treatment for his rib fractures on 21 December. He says this should have included antibiotics as he went on to develop a hip infection. He feels this would have prevented him from needing a hip operation and a lengthy hospital stay which he says impacted him financially as he was unable to begin a job.

31. As with an earlier section of this statement, our internal physician adviser explained there are no national guidelines on the treatment of rib fractures in hospital. NHS.UK webpage on ‘broken or bruised ribs’ says broken ribs cannot be splinted or supported like other bones, so clinicians usually leave them to heal naturally. It explains people can use painkillers and rest to help ease pain and speed up healing.

32. Our internal adviser explained we can use regional guidance from Healthcare Improvement Scotland and Imperial College Healthcare NHS Trust to understand how doctors typically assess and treat rib fractures in hospital. Both pieces of guidance suggest the use of scoring systems to define risk and level of input the patient needs.

33. Healthcare Improvement Scotland guidance says clinicians should calculate a person’s rib fracture score to determine appropriate treatment. They can calculate this by factoring in the number of breaks, whether the breaks are on one or both sides and the person’s age. The guidance explains appropriate treatment for rib fractures

34. Mr O was 56 years old in December 2023. The evidence suggests he had three rib breaks at this time. It is not clear whether these were on one or both sides. If the breaks were on one side his rib fracture score was four. If they were on both sides, his score was five.

35. The two pieces of guidance explain for a score between three and six the appropriate treatment is pain relief. This can be paracetamol, nonsteroidal anti-inflammatory drugs or oral opioids. Clinical records show clinicians prescribed Mr O oral morphine prior to discharge. This is an oral opioid meaning Mr O received pain relief in line with the above guidance.

36. Mr O considers the Trust should have provided him with antibiotics to him developing an infection. Our internal adviser explained that doctors do not prescribe prophylactic antibiotics (antibiotics to prevent an infection) for rib fractures. They referred us to a British Journal of Surgery journal article on ‘Evaluating the Use of Prophylactic Antibiotics in Patients with Chest Trauma’ which found they were not useful.

37. We understand why Mr O considers the Trust should have prescribed antibiotics. Nowhere in guidance does it stipulate doctors should prescribe antibiotics to prevent infection developing after rib fractures. Meaning we cannot say anything went wrong in the clinician’s decision not to prescribe these. We recognise this will be frustrating to Mr O as he considers his infection could have been avoided.

38. We have seen indicated failings as the Trust did not identify Mr O’s fractures. Despite this, the evidence suggests Mr O received clinically appropriate treatment for his symptoms, and this would not have changed if staff had identified three fractures on 21 December. We have seen nothing to suggest that the Trust’s actions had a negative clinical impact for Mr O.

39. We consider his infections, surgery and lengthy hospital stay were unavoidable and have seen nothing to suggest these were because of any mistake on the Trust’s part.

40. Mr O says he spent the period between 21 December 2023 and 12 January 2024 bedridden. He says the Trust’s actions caused tension with his family and partner as they believed he was lying about the extent of his injuries. His account of events suggests his family did not feel a muscle injury was serious enough to require bedrest.

41. The evidence we have seen suggests that Mr O would have spent the same amount of time bedridden had the Trust identified his rib fractures in December. We are sorry to hear that Mr O’s relationship broke down during the period of complaint. We recognise how distressing this was for him.

42. For us to link the impact he claims we would have to be able to say with certainty that his family’s or partner’s response would have changed if they knew he had rib fractures. There is not enough independent evidence for us to say this was the case. This is because we do not know if there were any extenuating factors separate to the complaint that affected Mr O’s relationship with his partner or family.

43. The Trust acknowledged what went wrong and apologised to Mr O for this in both its duty of candour letter and complaints response. It explained it has shared this with the radiologist responsible for interpreting the initial scan and they have taken learning.

44. Our Principles for Remedy say where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. Remedies may be financial or non-financial.

45. We have been unable to link the impact Mr O claims with any mistake on the Trust’s part. We are satisfied that the Trust has appropriately acknowledged what went wrong, apologised for this and taken learning. We consider the actions it has taken are proportionate and in line with our Principles. For this reason, we do not think it needs to do anything further. We recognise Mr O has been through a difficult time with his health and personal life since the period of complaint.

Communication

46. Mr O complains that during the period of complaint the Trust repeatedly misinformed his family about the extent of his injuries. It is not clear from his account of events when these conversations took place.

47. We reviewed Mr O’s clinical records from the period of complaint. There is no documentation of any contact between the Trust and Mr O’s family in December 2023. Nor is there any record of contact between 1 January and 25 January 2024.

48. The only contact between Mr O’s family and the Trust we can see during the period of complaint was on 26 January when Mr O’s daughter visited him in hospital. There is no evidence of Mr O’s family speaking with Trust staff again after this point.

49. Notes from 26 January show Mr O’s daughter spoke to a nurse as she was confused about her father’s condition. The nurse updated Mr O’s daughter about the surgery her father had undergone and the care he had been receiving. At this point clinicians had identified the full extent of Mr O’s injuries, and he had undergone surgery to remove and replace a hip replacement.

50. Mr O’s daughter told the nurse her father would like a written apology for doctors missing his broken ribs. Whilst documentation of the conversation is brief, the contents suggest the nurse provided accurate information about the extent of Mr O’s injuries.

51. We acknowledge Mr O says the Trust repeatedly misinformed his family about the extent of his injuries even after it had identified his rib and sternum fractures. We have found no independent evidence to support his account of events. We have not been able to identify an occasion where staff provided incorrect information about Mr O’s injuries to his family. We do not know what happened or when. This means we cannot then go onto reach a view on maladministration.

52. For us to investigate this further we need to have seen indications of maladministration and know when these occurred. As we explain above, there is not enough evidence to allow us to do so and progressing to an investigation would not change this. Therefore, there is no value in providing a response through an investigation as it is likely that even if we then went onto conduct a full detailed investigation, we would still face the same challenges that we cannot establish dates when this occurred. We do not consider a detailed investigation would provide us with any further opportunity for new evidence on which to reach a decision.

The Practice

53. Mr O complains that during two appointments doctors failed to recognise that his injuries needed further investigation. He considers they were wrong to rely on information from the Trust. He also complains that the Practice did not provide medication to treat his pain and infection.

54. The relevant guidance for this aspect of complaint is the GMC’s Good medical practice. This says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.

55. Good medical practice says doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs.

First appointment

56. Clinical records from 2 January show Mr O had undergone a CT scan in hospital. The scan report contained no mention of fractures. The GP examined Mr O and found he had tenderness but no bruising. The GP diagnosed Mr O with a soft tissue injury.

57. We discussed Mr O’s complaint with our GP adviser. They noted that Mr O had pain on breathing and explained that this is common with chest wall injuries even without fractures. Our GP adviser said the information available to the GP at the time of the appointment suggested Mr O had a chest wall injury and this was the conclusion the GP reached.

58. Mr O’s complaint suggests he considers the GP concluded nothing was wrong. We do not consider this was the case as the GP identified he had an injury. Our GP adviser said GPs do not receive copies of images from scans and would only see scan reports.

59. Good medical practice makes it clear doctors should arrange suitable investigations where necessary. It does not stipulate how GPs should interpret scan reports, our GP adviser said it is appropriate for GPs to accept their contents.

60. Our GP adviser explained there was no reason for the GP to suspect Mr O had rib fractures at this time, meaning further investigation was not clinically indicated. We consider the GP’s decision not to arrange further investigations was in line with Good medical practice.

61. In terms of medication, Mr O’s clinical records show the GP carried out full observations (measurement of heart rate, blood pressure, temperature, oxygen levels) which were normal. Mr O was taking pain relief at this point, and we have seen no evidence he told the GP his pain was not controlled.

62. Our GP adviser said there was no clinical indication for the GP to change Mr O’s pain relief during the first appointment. They noted Mr O also had a normal temperature and no signs of an infection so there was no reason for the GP to prescribe antibiotics at this time.

63. Good medical practice makes it clear that doctors must only provide treatment where necessary. We have seen nothing to suggest that Mr O needed a change in pain relief or a prescription of antibiotics during the first appointment. We consider the GP provided care in line with Good medical practice during the first appointment. We have seen no indication of failing in this aspect of the complaint.

Second appointment

64. Clinical records from 11 January show Mr O presented with the same symptoms. The only difference was that he told a GP his pain was no longer controlled. The GP increased Mr O’s pain relief and prescribe diazepam for muscle spasms.

65. We can see the GP examined Mr O and took his observations which again were normal. They noted Mr O’s clinical history and the scan report. Our GP adviser explained that as with the first appointment Mr O had a normal temperature and showed no signs of infection.

66. The GP told Mr O to contact the Practice again if his symptoms changed as he may be at risk of developing a chest infection. Our GP adviser said this was clinically appropriate safety netting as Mr O’s chest wall injury could affect his ability to breathe deeply which would increase the risk of chest infections.

67. Good medical practice makes it clear that doctors must only provide treatment where necessary. Our GP adviser confirmed that the GP’s decision to increase pain relief and prescribe diazepam was clinically appropriate for a chest wall injury which was the existing diagnosis at the time. They said there is no indication that Mr O had an infection on 11 January meaning there was no need for the GP to prescribe antibiotics.

68. We accept Mr O did have rib fractures and needed further investigation. We cannot say that the Practice should have identified Mr O needed further investigation during either appointment as they did not have any evidence this was the case until Mr O’s second hospital admission.

69. We recognise Mr O went on to develop a chest infection and hip infection. He became unwell in January 2024, and this led to him needing surgery to remove and replace a hip replacement. It is clear from his account to events that his recovery was extensive and difficult. We do not underestimate this. We have seen nothing to suggest this was because of any mistake on the Practice’s part. We have seen no indication of failing in either appointment. For this reason, we are not continuing our consideration of Mr O’s complaint.

1. We have carefully considered Mr O’s complaint about Royal United Hospitals Bath NHS Foundation Trust (the Trust) and a practice in the Wiltshire area (the Practice). We are sorry to hear of the pain and distress he experienced during the period of complaint.

2. We have seen no indication that anything went wrong with the issues Mr O raises about the Practice.

3. We have seen indications that something went wrong with the care the Trust provided on 21 December 2023. Specifically, that it did not identify three rib fractures on his scan. We have not seen evidence that this had a clinical impact on Mr O, nor have we been able to link this with the impact he claims. We have decided the Trust has already done enough to remedy any remaining impact on Mr O.

4. Regarding Mr O’s complaint about the Trust’s communication with his family. We have not been able to reach a view on maladministration. This is because we have seen no independent evidence to help us understand what happened.