Epsom and St Helier University Hospitals NHS Trust

5. Miss A complains about aspects of the care and treatment provided by Epsom and St Helier University Hospitals NHS Trust (the Trust) between 31 March and 17 April 2025. Specifically, Miss A complains the Trust did not:

• diagnose her fractured ankle and • provide the correct treatment for a fractured ankle.

6. As a result of the above, Miss A says her ankle has not healed as it should have and she is still experiencing pain and discomfort.

7. As an outcome to her complaint, Miss A seeks a financial remedy.

8. On 30 March, Miss A sustained an injury to her left ankle which caused her intense pain. She rested the ankle to see if it would improve.

9. On 31 March, the pain had not improved so Miss A called 111. She was advised to visit her local urgent care centre, which she did. An emergency nurse practitioner (ENP) triaged Miss A and organised for her to undergo an X-ray. Once the results of the X-ray were received, Miss A was told her the ankle injury was a sprain, and she should ice and rest her ankle. Miss A then went home.

10. On 2 April, the Trust sent Miss A a text message letting her know it had sent her X-ray to the fracture clinic. There was no further information on this message.

11. 0n 9 April, Miss A received a letter from the fracture clinic, which stated ‘no bony injuries have been seen.’ The letter further stated Miss A was discharged from their service.

12. Miss A was still in pain, so she visited her GP who prescribed her with painkillers and suggested she use a boot and/or crutches.

13. Miss A also had private medical insurance through her employment, who organised for her to see a physiotherapist regarding her ankle pain. The physiotherapist referred Miss A to see a senior consultant who organised for her to undergo a magnetic resonance imaging (MRI) scan. An MRI scan takes detailed pictures of the inside of your body and provides better imaging than other imaging methods.

14. On 17 April, the MRI scan showed Miss A had an undisplaced fracture of the distal fibula with more pronounced cortical breach in the lateral cortex and periosteal reaction. This is a small break in the outer bone of the lower leg near the ankle where the bone pieces are still in their normal position. The consultant told her to use crutches and a boot for seven weeks.

18. Before we decide if we should investigate a complaint in more detail we look at whether there are any signs the Trust got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, this indicates a failing.

19. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the Trust has done to try and put things right.

Diagnosis and Treatment

20. Miss A believes the Trust failed to diagnose her fractured ankle during her visit to the emergency department (ED). She says the ENP did not physically examine her ankle and provided little information about her condition before sending her for an X-ray. After the X-ray, Miss A says the doctor told her the injury was a sprain and advised her to rest and ice her ankle, even though they had referred her to the fracture clinic for further consideration.

21. Miss A is also concerned the fracture clinic did not find a fracture as she later had an MRI scan privately which showed this. She says the Trust’s failure to diagnose her injury earlier caused her unnecessary pain, distress, and uncertainty. She is also concerned that there was a 2-week delay in treating her fracture with a boot.

22. The Trust explains the ENP assessed Miss A appropriately during her visit and ordered an X-ray based on her symptoms and ability to bear weight on her ankle. The ENP diagnosed Miss A with a sprain because the X-ray did not show any signs of a fracture.

23. After the radiology team identified a possible stress fracture, the ENP referred Miss A to the virtual fracture clinic. The clinic reviewed the X-ray but concluded there were no bony injuries and discharged Miss A.

24. The NHS emergency departments guidance provides advice around the type of initial assessment that can be expected by patients when they arrive to an emergency department. It says the main objectives of initial assessment are to:

• accurately assess non-life-threatening conditions and injuries so that appropriate prioritisation occurs for patients, and they are seen by the right service within appropriate timeframes.

25. The guidance also recommends an initial assessment should ensure appropriate service allocation, identify immediate clinical care needs and defines ‘streaming’ as a ‘clinical activity to direct patients to the most appropriate service based on their presenting symptoms, chief complaint and acuity.’

26. It is based on a clinical assessment that typically involves taking a brief medical history and may include basic observations. It says the streaming activity should be brief, to avoid queues developing, and completed as soon as possible.

27. NICE fracture guidance and NICE sprain assessment guidance recommends using the Ottawa ankle rules to help clinicians decide whether a patient requires an X-ray following an ankle injury.

28. The Ottawa rules recommend an ankle X-ray if there is pain in the malleolar zone and any one of the following:

• inability to bear weight (walk four steps) immediately after the injury and when examined, • bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, and • bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

29. This guidance is further supported by the by the Royal College of Emergency Medicine in their learning module on ankle injuries. Clinicians are expected to take an appropriate history, carry out a physical examination and use recognised clinical tools, such as the Ottawa ankle rules, when assessing ankle injuries.

30. Our emergency consultant adviser says assessment in the emergency department would include taking a full history to cover how the injury occurred and other factors such as any significant associated injuries, past medical, drug and social history and physical examination looking for tenderness as per the Ottawa rules.

31. Our emergency consultant adviser says formal clinical assessment would not be incorporated into this process as streaming nurses are not required to be trained in clinical assessment. Our adviser says the aim is to match a patient needs to the practitioner and area with the right clinical skills, diagnostic and treatment capabilities at the earliest opportunity.

32. The records show the ENP took a history, recorded how the injury happened, examined the ankle, recorded tenderness and noted Miss A could bear weight on it. They completed an initial assessment and identified Miss A had a non-life-threatening condition/injury and subsequently ensured appropriate service allocation to the urgent treatment centre.

33. Based on the evidence above, we can see most of these areas were covered in the initial assessment, in line with the NICE fracture guidance, sprain assessment guidance and NHS emergency departments guidance.

34. While the medical notes do not specifically document a physical examination of the ankle, we can see it recorded no swelling but bony tenderness and in line with the Ottawa rules Miss A was sent for an X-ray. As such, we cannot see the Trust acted against guidance during the assessment.

35. The NHS diagnostic imaging guidance expects organisations to have systems in place to review imaging results, communicate significant findings and arrange appropriate follow up where necessary. It discusses turnaround time (TAT) which is the time between an x-ray and a verified report being made available to the referring clinicians. The guidance states the service for ED patients should have a maximum TAT of 12 hours.

36. This is further documented in the radiology guidance, which refers to a local target turnaround times for reporting emergency department X-rays at two days.

37. The emergency medical service guidelines refer to standards regarding the management of investigation results in the emergency department. This says all emergency departments must have a ‘standard operating procedure’ for the handling of investigation results, for patients under the care of the ED or discharged from the emergency department.

38. It states the standard operating procedure must have:

• the process of review and action taken must be identifiable and traceable, and completed in a timely fashion. This must be real time for critical investigation results, and 72 hours for non-urgent results.

• the systems in place for referral follow up and further action required.

• mechanisms of informing the patient of the action taken.

39. BOAST ankle fracture guidance provides standards for practice when dealing with ankle fractures and injuries. It says ‘fractures considered stable should be treated with analgesia, splinting and patients allowed to bear weight as tolerated. Further follow-up may not be necessary.’

40. Our adviser reviewed the X-ray taken on 31 March and confirmed there is a callus formation within the distal fibula suggesting a fracture. We asked our adviser whether it would be reasonable to expect the fracture to be visible on the X-ray as the notes state no obvious bony injury seen. Our adviser confirmed it would be reasonable to see however the X-ray changes are subtle and could easily be missed on ED review, hence the need for formal reporting of the X-ray imaging to radiology.

41. Miss A was discharged before the X-ray was formally reviewed by radiology. She was told her injury was a sprain and she was provided safety netting advice.

42. When the radiologist reviewed the X-ray and identified an abnormality which indicated a possible fracture, Miss A was promptly referred to the virtual fracture clinic. However, the virtual fracture clinic also reviewed the X-ray and concluded no fracture was apparent on the X-ray.

43. The fact that different clinicians interpreted the X-ray differently indicates the abnormality could have been subtle and difficult to identify.

44. Our adviser explained it would not be practicable or desirable for patients to remain in the ED for a formal radiology review. Based on the NHS diagnostic imaging guidance, radiology guidance and emergency medical service guidelines and the suggested timeframes, we can see it would not be reasonable for Miss A to remain waiting in the ED until her X-ray was formally reviewed.

45. We can see the Trust acted in line with guidance and its own policy by sending the X-ray for a formal review and once the radiologists confirmed a potential fracture, a prompt referral was made to the virtual fracture clinic.

46. We understand the MRI scan later confirmed an undisplaced distal fibula fracture. However, the fact that a later investigation identified a fracture does not mean the earlier diagnosis was unreasonable. We must consider whether the Trust acted appropriately at the time by only carrying out an X-ray which did not conclusively show the fracture.

47. Having considered the records, the guidance and the independent clinical advice, we find the Trust acted reasonably when they assessed the X-ray and diagnosed an ankle sprain.

48. We understand Miss A says she was not provided with the correct treatment which affected her pain and recovery.

49. Our orthopaedic adviser explained if clinicians had identified a fracture earlier, they would likely have provided a splint or a boot and crutches sooner. The adviser also explained the fracture was undisplaced and stable, and this meant receiving the boot or splint earlier would not have affected the healing process, shortened the recovery period or changed the long-term outcome of the injury.

50. We recognise Miss A experienced ongoing pain and uncertainty before clinicians identified the fracture over two weeks after the initial injury. Earlier provision of a split or boot would have reduced some of that discomfort. We have however not seen any indication earlier treatment would have changed the overall outcome of the injury.

51. Miss A told us she wanted a financial remedy to recognise the physical and emotional impact she experienced because of the delay in receiving treatment. We carefully discussed this with the Trust who agreed to make a payment of £600 to Miss A to recognise the pain and distress she experienced from not receiving the splint or boot earlier. Miss A confirmed she was happy to accept this offer to resolve her complaint.

52. Taking all this into account, we are satisfied the Trust recognised the impact the delay in treatment may have had on Miss A. It has offered an appropriate financial remedy in line with our severity of injustice and has met the outcome Miss A was seeking when she brought her complaint to us.

53. We are satisfied we have been able to successfully resolve Miss A’s complaint. We would like to thank both parties for their cooperation and understanding during this process.

1. We have carefully considered Miss A’s complaint about aspects of care and treatment she received from Epsom and St Helier University Hospitals NHS Trust (the Trust).

2. We are sorry to hear of the distress caused to Miss A from the delay in receiving treatment for her fractured ankle and we thank her for bringing her complaint to us.

3. We would like to reassure Miss A that we have not seen any indication the Trust did not correctly diagnose her ankle injury or provide appropriate treatment for her injury. However, we find there was a delay in Miss A receiving treatment which would have caused her additional pain and distress. We hope our explanation below explains how we reached our decision.

4. We are grateful for Miss A’s time and effort in bringing her complaint to our attention. Complaints give us a valuable insight into the organisations we investigate, so we would like to thank Miss A for sharing her experience with us.