Whittington Health NHS Trust

6. Mrs M, represented by her children, complains about care she received from the Trust. The Trust admitted Mrs M in September 2023 after she had a fall. She says the Trust:

• did not properly consider whether she had a wrist fracture when she first arrived and would not agree to an X-ray • took more than a week to investigate the pain in her wrist and take an X-ray • did not provide the correct equipment to immobilise her wrist throughout her admission or at discharge.

7. As result, Mrs M explains she was left in significant pain for seven days. She says she underwent physiotherapy on her wrist when it should have been immobilised and the collar and cuff sling put additional pressure on the area. She explains she has now lost a significant amount of dexterity and movement in her hand and wrist. This has meant she is no longer able to do household chores, look after herself and her husband properly, or take part in her hobbies.

8. To resolve the complaint Mrs M would like the Trust to put improvements in place to stop the same issues happening again. She would like a financial remedy.

9. In September 2023, Mrs M had a fall whilst on holiday. The doctors in the local hospital diagnosed a fractured shoulder.

10. Mrs M returned to the UK within a few days, and her GP urgently referred her to the fracture clinic at the Trust which she attended the same day.

11. An orthopaedic surgeon examined Mrs M and arranged for X-rays to her shoulder and hip. The orthopaedic surgeon also examined her wrist but did not think it was fractured and decided against an X-ray of this area.

12. The X-rays, taken the same day she arrived, identified Mrs M also had a fracture in her prosthetic hip alongside the shoulder injury. The Trust admitted her and provided a broad arm sling (a support for the whole arm, commonly used in treating shoulder injuries).

13. Around a week after the Trust admitted Mrs M, it swapped her broad arm sling to a collar and cuff (a strap that loops around the neck and wrist commonly used to support shoulder injuries).

14. Shortly after, Mrs M complained of pain in her wrist and within a day the Trust agreed to X-ray it. This showed a distal radius fracture (a break in the forearm bone near the wrist) which had healed and signs of a new un-displaced (stable) refracture. This means Mrs M had a previously undiagnosed fracture injury which had healed but she had fractured it again during her recent fall.

15. The Trust then provided Mrs M with a futura splint (an adjustable wrist brace designed to stabilise wrist injuries), to use alongside the collar and cuff.

16. The Trust discharged Mrs M around one week later.

Initial refusal to X-ray and delay before diagnosis

23. Mrs M told us when she presented to the Trust she had pain in her wrist. She says the clinician was preoccupied with her other injuries and she does not think they properly assessed her wrist. She is unhappy the Trust would not agree to X-ray it despite her family insisting it was broken. She says the Trust was dismissive in this initial assessment but a week later diagnosed her with a fractured wrist.

24. The Trust says it assessed her wrist in the fracture clinic, including manipulating the wrist to check for mobility but found no suggestion of a fracture. It considered its decision not to X-ray Mrs M’s wrist at the outset was reasonable. It acknowledged it found the fracture when her pain increased a week later. It apologised if Mrs M felt its staff were dismissive.

25. GMC guidance says clinicians should consider a patient’s symptoms and history to provide suitable investigations and treatment. It says clinicians should work in partnership with their patients.

26. There are no records from the initial assessment within the fracture clinic and so we have therefore relied on the accounts of Mrs M’s family and the Trust’s view in its complaint response in considering this point.

27. Mrs M’s representatives gave a detailed account of the assessment. They told us the clinician moved her wrist with two fingers and a thumb, which they did not think was a thorough examination of the area. They told us despite this movement causing pain, the clinician only considered her wrist briefly.

28. They recalled the clinician explaining her wrist was unlikely to be broken and attributed its swelling to her shoulder injury. Mrs M’s representatives explained how they firmly stated something was wrong with her wrist and that she needed an X-ray, but the clinician was dismissive of them.

29. Based on the description of the injured area in the complaint response and the notes while Mrs M was admitted, our orthopaedic adviser explained there is no evidence Mrs M’s wrist was grossly misshapen or severely bruised. Therefore, it was not obvious it was fractured.

30. Our orthopaedic adviser explained manipulating the wrist to check for pain and assess its range of movement would be normal as part of an examination of this kind of injury. It appears from the accounts of both Mrs M’s representatives and the Trust that it did carry out an examination in this way.

31. Our orthopaedic adviser told us an assessment should take into consideration information provided by the patient and their family during an assessment. Mrs M and her children were clearly concerned about the wrist and pushed for further investigation.

32. Our orthopaedic adviser said the Trust should have also considered the details about what happened as part of this initial assessment. They said the Trust should have given serious consideration to the fact Mrs M had fallen and sustained two other serious injuries and also clearly had pain in her wrist.

33. This is supported by NHS information on distal radius fractures which explains they most commonly occur where a person has tried to break their fall and in people over the age of 60. Considering this, alongside the fact she had other injuries, we consider Mrs M would have been at high risk of having a fractured wrist.

34. We would expect the Trust to have considered Mrs M’s age, and how she used arm to break her fall, which also caused two other serious injuries. We think the decision not to X-ray her wrist indicates the Trust failed to complete a thorough assessment in line with GMC guidance. Also, her family were clearly concerned something was wrong at the very least an X-ray of the wrist would have eased these concerns.

35. We recognise this came down to a clinical opinion on the day. Given the available evidence, it appears the Trust should have agreed to X-ray Mrs M’s wrist when she first presented.

Failure to diagnose during admission

36. Mrs M is also concerned it took over a week to diagnose the fracture after she was admitted to hospital. She told us she had pain in the wrist during her admission, but it was not until the pain intensified after one week that the Trust agreed to X-ray the area.

37. GMC guidance says clinicians should adequately assess their patients and provide appropriate treatment where necessary.

38. Having reviewed the records, including the clinical, nursing and physiotherapy notes we cannot see any instances where Mrs M specifically complained about her wrist during the first few days on the ward. We can see during this time the Trust recorded when she had pain in her shoulder, hip and sometimes her left arm, showing it was monitoring her pain.

39. A few days after admission the notes say she was able to ‘weight bear through upper limbs’ indicating she could hold herself up with both arms.

40. We therefore have different perspectives from Mrs M and the Trust. The Trust does not have any record of Mrs M complaining of pain specifically in her wrist during the first week of her admission. Mrs M’s representatives are clear she did mention this to the Trust. We recognise she was in a lot of pain due to her having multiple injuries.

41. Our orthopaedic adviser emphasised the seriousness of both the shoulder and hip injuries, and that these would be the priority of the clinicians treating her on the ward. They added the shoulder injury would likely have caused pain and swelling throughout Mrs M’s whole left arm. We consider these factors might have made it more difficult for the Trust to identify the injury to her wrist.

42. Around a week after admission the Trust changed Mrs M to a collar and cuff which Mrs M says put pressure on her wrist. She reported the pain and the Trust then agreed to X-ray the area. The Trust diagnosed the fracture a day after Mrs M’s pain increased. This shows when her pain escalated, the Trust re-considered her symptoms and arranged for further investigation. This appears to be in line with GMC guidance.

43. Based on the evidence we do not think we can say the Trust should have identified her injury sooner during her admission. This is notwithstanding our thinking above in respect of the initial decision not to carry out an X-ray.

Equipment to immobilise wrist

44. Mrs M is unhappy she was not provided with appropriate equipment to support her wrist. She is not happy it took a week to provide her with a collar and cuff and that this piece of equipment was ‘makeshift’ as it was a strap adapted from a different sling. She says she had no supporting equipment for her wrist at all for the first week and the futura splint she received on after the first week did not help adequately.

45. The Trust did not provide any support for Mrs M’s wrist during her first week of admission as it had not diagnosed the fracture.

46. The Trust initially provided Mrs M with a broad arm sling and changed to a collar and cuff one week into Mrs M’s admission. She then used the collar and cuff throughout the admission, and she still had it at discharge.

47. Our orthopaedic adviser confirmed there is no specific guidance on exactly which support or cast should be used on a specific injury. They explained this would be down to the clinical judgement of the clinician alongside preference of the Trust.

48. Our orthopaedic adviser explained the broad arm sling and collar and cuff were used to help with the healing of Mrs M’s shoulder. This equipment was not used to treat her fractured wrist. As Mrs M has asked us to consider the impact the equipment had on her wrist, we have not considered the specific type of collar and cuff used in detail.

49. After the Trust diagnosed Mrs M’s fractured wrist, it provided her with a futura splint. We recognise Mrs M did not find the futura splint helpful. Our orthopaedic adviser explained a futura splint was a good option for Mrs M’s stable fracture as it allows movement sooner. This helps reduce stiffness after healing, which is a concern with elderly patients.

50. GMC guidance says clinicians should adequately assess a patient’s condition and provide appropriate treatment and we think the Trust acted in line with this. In line with this, the Trust considered the type of fracture and which equipment was best based on Mrs M’s individual circumstances.

51. In summary, we have not seen any indications of failings in regard to the equipment the Trust provided once it diagnosed Mrs M’s wrist fracture.

Our consideration of the impact

52. As above, there are indications the Trust should have agreed to X-ray Mrs M’s wrist when she first arrived. If it had done so, it is reasonable to say it would have shown the fracture. It therefore appears there was a delay of one week in diagnosing the fracture.

53. We have therefore considered what would have been different for Mrs M had the Trust found the fracture at the time of her initial admission.

54. Mrs M told us at the outset of the complaint she was caused significant additional pain for a week.

55. Considering what might have been different had the Trust found the fracture sooner, it would have provided a futura splint one week sooner. This is because this is the treatment it provided after her diagnosis. The purpose of the futura was to try to help with her pain.

56. Mrs M told us that even after she had received the futura splint from the Trust, this had almost no impact on the pain she experienced. It was only after she received a plaster cast, some weeks later as an outpatient, that the pain in her wrist reduced significantly.

57. We can see from the records that Mrs M was in pain both before and after the wrist diagnosis. Four days after the wrist fracture diagnosis it is recorded, ‘Patient complaining of continuous pain in left side’. We must consider Mrs M had very serious injuries and likely would have been in pain regardless of when the Trust found her wrist fracture. Our orthopaedic adviser also told us her shoulder injury would likely have caused her additional pain throughout her left arm.

58. It is very difficult for us to say for certain, or to what extent, an earlier diagnosis would have led to reduced pain during the first week of Mrs M’s admission. It seems unlikely, even had she had the futura splint sooner, her pain would have been meaningfully reduced.

59. When the Trust provided a collar and cuff, Mrs M says it put direct pressure on her wrist as it did not have any additional support. Shortly after the change, the Trust agreed to X-ray the wrist and diagnosed the fracture one day later.

60. The records after the Trust provided a futura splint show her pain was checked and managed by the Trust similarly to how it was prior to her collar and cuff. While still uncomfortable, the futura splint appears to have helped to support her wrist when wearing the collar and cuff and brought her pain down to a similar level as the first week of her admission.

61. Mrs M also feels that had she been diagnosed with the fractured wrist, she would not have had physiotherapy on it. Mrs M was undergoing functional rehabilitation sessions to optimise her being able to function independently with her daily activities at home. Our physiotherapy adviser explained this physiotherapy was important to assist with Mrs M getting home and being able to cope independently.

62. Our physiotherapy adviser explained there is no evidence of physiotherapy specifically on the wrist itself. They said specific physiotherapy on the wrist to help work on things like improving range of motion would be very unusual in a hospital setting.

63. We have not seen any evidence that the physiotherapy Mrs M received would have been any different had the Trust diagnosed her wrist fracture sooner. These sessions were important to get Mrs M fit enough to return home.

64. Mrs M told us her wrist has healed with significant stiffness, and she can no longer move or use it properly. She explained to us that her other injuries, which the Trust discovered on admission and then treated, had healed well. She feels this shows the late diagnosis, lack of treatment and physiotherapy while injured negatively impacted its healing.

65. We know Mrs M continues to have problems with her wrist and this impacts on her ability to live a normal life. We are sorry this has had such a profound impact on her.

66. The X-ray of Mrs M’s wrist showed she had a stable, undisplaced fracture which our orthopaedic adviser explained means the bones had not moved and had remained in their original alignment following the fracture. They explained the bones did not need to be re-aligned and the X-ray showed they had been stable throughout Mrs M’s stay in hospital.

67. Our orthopaedic adviser gave their view the only difference with an earlier diagnosis was a futura splint would have been offered sooner to help with Mrs M’s pain. We know a futura splint allows the wearer to remove it and allows some movement which is good for long-term healing. This would indicate that Mrs M not having her wrist immobilised in the first week was unlikely to have had any impact on the healing of the injury.

68. Our orthopaedic adviser explained the injuries to the wrist, shoulder and hip were separate and would heal separately. We cannot say because Mrs M’s other injuries healed well the wrist would have been the same.

69. Our orthopaedic adviser told us stiffness is always a risk in elderly patients with wrist injuries. They added that the old injury (the previously undiagnosed wrist fracture) was a further risk factor. As Mrs M had re-injured the same wrist, she was more likely to experience additional stiffness when it healed.

70. Our orthopaedic adviser gave their opinion that an earlier diagnosis would not have made any difference to Mrs M’s recovery.

71. Considering all this, we do not think we can link the delay in diagnosis to the long-term impact on the dexterity of her wrist described by Mrs M. We do not wish to diminish the effect this injury has had on her.

72. When considering the impact of a potential failing, we consider our severity of injustice scale. Level 1 of our scale includes short term pain of one to two days.

73. We think the impact of the delay was that Mrs M was caused additional pain between fitting of the collar and cuff and being provided a futura splint the next day. We feel this impact falls in line with Level 1. We would generally consider an apology to be an appropriate remedy for level 1 injustice.

74. In its complaint response letter, we can see the Trust apologised to Mrs M for the ‘significant pain’ she experienced when it changed the sling to a collar and cuff. As it apologised, we are satisfied the Trust has taken action to remedy the impact of the pain caused to Mrs M.

75. We would like to again acknowledge the significant impact on Mrs M and know she will likely have life-long problems with her wrist. We are sorry this happened and hope our statement has helped to explain to Mrs M that this likely could not have been prevented.

1. Mrs M complained to us about Whittington Health NHS Trust (the Trust). We were sorry to learn about her fall while on holiday and the serious injuries she sustained. This must have been a very difficult time for her, and we know she feels the Trust’s actions have negatively affected her recovery from her wrist injury.

2. We have carefully considered the available evidence and there are indications the Trust should have agreed to X-ray Mrs M’s wrist sooner than it did. We think this led to her experiencing some additional pain for around one day. We have not been able to say this potential problem was linked to the other impacts Mrs M described.

3. In the Trust’s complaint response, we can see the Trust apologised for the pain Mrs M experienced. Based on this, we consider the Trust has addressed the impact it caused and we will not take further action.

4. We have not seen anything else went wrong in respect of Mrs M’s complaints about what happened during her admission or with the choice of equipment to stabilise her wrist. We will therefore take no further action on these points.

5. We hope our comments and consideration brings Mrs M and her family some answers about the care she received.