Suffolk and North East Essex Integrated Care Board

Stowhealth Ask my GP

5. Mrs R complains about the advice given by the Ask my GP service provided at her GP in Stowmarket. She made contact in March five days after a fall where she hurt the little finger on her right hand.

6. She says she was not referred to A&E by the service and when she did attend (as the pain did not settle), an X-ray found she had fractured the finger.

West Suffolk NHS Foundation Trust

7. Mrs R says that after A&E referred her to the Trauma and Orthopaedic clinic, she was not seen face to face with instruction on treatment provided during a phone appointment.

8. She says when she received the letter with details of the phone appointment, it said she should strap the finger, but the nurse had not stipulated this when Mrs R told them she had not strapped the finger during the call.

9. Mrs R says she now has a malunion fracture because she was not given the correct advice by the Ask my GP service, A&E or the trauma and orthopaedic clinic.

10. She says that had she been referred to A&E in the first instance, this would not have been the case.

11. Because of the fracture, she says her right-hand little finger is deformed, and she has lost function in the finger as well as experiencing stiffness.

12. Mrs R would like the ICB to recognise both organisations were negligent and would like a financial payment of £3700 (level four of our severity of injustice scale) in recognition of the impact of the negligence.

13. Mrs R is a lady in her late fifties. She regularly runs to keep fit.

14. During a run Mrs R fell and hurt the little finger on her right hand.

15. Five days later, she used the Ask my GP service at the Surgery. She was told it may be fractured but would need to attend A&E for an X-ray to establish if this were the case. She was given advice to strap the finger, use ice to reduce swelling and to attend A&E should the pain and swelling not improve in the next seven days.

16. Eight days later, she attended A&E who arranged for an X-ray and for an appointment with T&O.

17. She had a phone appointment with T&O who confirmed a fracture to the right-hand little finger. She was given advice on how to manage this both during the call and in writing after this.

GP Surgery in Stowmarket

Incorrect advice

21. Mrs R complains she was not given the correct advice by the Ask my GP service at the Surgery. She says she contacted the service five days after a fall as she had hurt the little finger on her right hand.

22. She says the Surgery ought to have referred her to A&E to have an X-ray rather than telling her to strap the finger and see whether this improved over the next week. In addition, they said she could continue to use an ibuprofen (a non-steroidal anti-inflammatory used to reduce pain and swelling) gel to ease pain, but T&O later told her not to take ibuprofen.

23. In its response to Mrs R and the ICB, the Surgery said the physician associate (a healthcare professional who works under the supervision of a doctor) who dealt with the Ask my GP query viewed photographs of the finger and asked questions of Mrs R. It said she was advised to attend A&E for an X-ray if she wanted to establish whether the finger was broken, but the likely treatment would be to neighbour strap (strap the finger to the finger next to it) the finger.

24. The response does not say whether the correct treatment had been provided or whether Mrs R ought to have been advised to attend A&E at the time of the contact.

25. 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, in line with guidance and standards.

26. In reaching our decision, we have considered the information on the NHS website in respect of broken fingers or thumbs. This suggests contacting NHS 111 in the first instance and that it is not necessary to attend A&E immediately unless the finger is ‘pointing at an odd angle, looks blue or feels numb, is cut and you can see bone through it’.

27. This goes on to say usual treatment is to straighten the finger and to strap to an adjacent finger to keep it in position. It suggests the use of ice packs, paracetamol, and elevating the hand to reduce swelling. It does refer to some breaks needing a cast or surgery in extreme circumstances and that it can take as long as three to four months for a break to heal.

28. We also considered NICE guidance on fractures and pain relief. This says, ‘You may also be given a type of painkiller called a nonsteroidal, antiinflammatory drug (NSAID), (for example, ibuprofen)’.

29. Mrs R raised a query with the Surgery’s Ask my GP service five days after hurting her finger. She included photographs of the finger. The transcript of the conversation shows the physician associate asked whether Mrs R could move the finger normally and what increased pain as well as what she had been doing to help her injury in the first instance.

30. In her response, Mrs R explained she could not move the finger normally, potentially due to the swelling and that using the hand worsened her pain. She said she had used ice and an ibuprofen gel to help.

31. The physician associate said it may be a fracture of the finger but that could only be established by attending A&E for an X-ray. They explained that the usual treatment given by A&E would be strapping to the adjacent finger (neighbour strapping), something Mrs R was able to try for a week to see if that helped.

32. They also said to continue with ice packs and pain relief and that it could be a few weeks before Mrs R would feel any improvement.

33. We asked our GP adviser about the Ask My GP advice and whether it had been appropriate for Mrs R.

34. They said the advice was correct as the only way to determine whether Mrs R had a fracture or break of the finger was to attend A&E for an X-ray. They said it is also likely she would be advised to strap the finger by A&E, which is what the physician associate had said.

35. They went on to say that Mrs R was told what she was able to do other than attend the A&E as she was advised to ‘try’ strapping for a week. Mrs R did not attend A&E until eight days after this.

36. Our nurse adviser said she did not think the advice given was written as clearly as it could have been but despite that, it was correct and gave Mrs R appropriate options.

37. When we asked whether there was any impact to the healing process due to Mrs R not being told to go to A&E immediately, our GP adviser said there was nothing to indicate this was the case. They said the advice given by T&O had been to strap the finger, which is what the physician associate had recommended, and so it was the same treatment.

38. This recommendation is also in line with the information on the NHS website as this explains the usual treatment to be neighbour strapping with ice packs, pain relief and elevating the hand.

39. In its response to Mrs R’s complaint, the ICB says that NSAID’s are not appropriate for long term treatment of fractures but may be given in the short-term dependant on the individual.

40. NICE guidance says ibuprofen may be given to patients with fractures. Our orthopaedic adviser said there is a school of thought about the suitability of NSAID’s for treating fractures. This is not reflected in guidance and there are ongoing studies into the effectiveness of NSAID’s for fracture patients. This is reflected in the response provided by the ICB.

41. In the messages exchanged through Ask my GP, the physician associate questioned Mrs R as well as looking at the photographs she had provided. From this, she was provided advice that is in line with NHS and NICE guidance.

42. In addition, the physician associate said if Mrs R wanted to know whether she had fractured the finger she would need to go to A&E for an X-ray, but the likely treatment would be strapping. Our GP adviser confirmed this was the correct advice, and it was correct to suggest she try this at home for a week. When she did attend A&E, she was advised to strap the finger. We consider the physician associate had been correct in their responses to Mrs R.

43. Our nurse adviser said the advice given could have been written more clearly, but that it was the correct advice. We consider this is a shortcoming but does not fall far enough below guidance and standards to be found a failing as the information provided was correct.

44. We are pleased to see that in its response to Mrs R, the Surgery recognises the information in the Ask my GP messages could have been clearer and that it intended to discuss this in a multidisciplinary team meeting (meetings of staff from different disciplines, such as nurses, doctors, associates), despite there being nothing to show it provided incorrect information.

45. In view of the above, we have not seen any indication that the Surgery did anything wrong in respect of the advice of provided through its Ask my GP service. The advice was in line with guidance, and we do not require the ICB act further in respect of this.

46. We recognise Mrs R experienced pain and discomfort at this time which will have been unpleasant and worrying for her.

West Suffolk NHS Foundation Trust

Conflicting advice

47. Mrs R says after A&E referred her to T&O; she received a call four days later. During the call, she was given instruction on treatment including strapping the finger. When she said she was not doing this, she was not told she needed to.

48. She says when she received the letter with details of the advice given it said she should strap the finger. Mrs R said that she did not do this as when she had the phone conversation, there had not been any concern shown about her not doing so. She considers this contributed to the fracture not healing properly.

49. In its response to Mrs R, the ICB explained that the intra-articular fracture (where the fracture crosses a joint surface) she had suffered carries risk of degeneration in the future and had she attended A&E immediately after the injury, surgery may have been an option.

50. The ICB goes on to say that due to the delay in attending A&E, conservative management (non-invasive treatment) was appropriate. It also said it can take as long as 18 months or more before full movement returns.

51. When making our decision, we considered the BSSH information on closed hand fractures and its hand injury triage guidelines. This includes an on-line questionnaire which, when completed by our orthopaedic adviser suggested ‘give pain relief...offer buddy taping (neighbour taping) for comfort’.

52. From the A&E records, we can see it is noted Mrs R attended with tenderness over ‘proximal phalanx (the first long bone of each finger), little finger’. An X-ray was arranged as the clinician considered there may be a fracture. The X-ray confirmed this to be the case as Mrs R had a mild displaced oblique fracture (a diagonal bone break where the fragments are slightly misaligned, not generally requiring surgery) of the base of the finger.

53. The records say Mrs R was advised to elevate the hand, take pain relief, apply ice and regularly move the finger. In addition, she was given a virtual appointment with T&O.

54. The virtual appointment took place four days later. The letter sent on the same date said that as the fracture was two weeks old, there was no need for Mrs R to be seen. It said the fracture was in an ‘acceptable alignment’ and that she should strap for up to four weeks.

55. In the letter, details of the telephone appointment say Mrs R was asked if she had ‘buddy’ strapped the finger, but she said not, and she was comfortable not strapping. It says she was advised to move the finger gently and was given details of how to self-refer for physiotherapy.

56. We asked our orthopaedic adviser what should happen have happened when Mrs R attended A&E once it had found she had a fracture to the right-hand little finger. They said that where a finger is fractured, it should be put back in place and strapped to keep it in place.

57. They went on to say that as it was 13 days since the injury happened, the healing process had started, and the bone would have been ‘sticky’ (healing) when she was seen. They said the X-ray records say the finger was not bent, rotated or showing signs of angulation or deformity. They explained the description ‘mildly displaced’ referred to the bone and not the appearance of the finger.

58. In respect of the virtual appointment with T&O, our orthopaedic adviser confirmed the record of the conversation in the letter sent after the appointment showed the advice given to be correct.

59. They went on to say the information in the letter was both clear and informative. It explained the importance of physiotherapy as well as how to treat the fracture. In addition, the service remained open to Mrs R for a period of three months, which gave her the opportunity to go back if she was unhappy with the healing process.

60. There is no guidance specific to fractures of the little finger, only generic advice for fractures and hand injuries. BSSH guidance on hand injuries gives generic advice such as strapping and taking pain relief. From the medical records and from what our orthopaedic adviser said, both A&E and T&O followed the guidance in the management of Mrs R’s fracture.

61. Taking the above into consideration, it appears that both A&E and T&O gave the correct advice and treatment to Mrs R.

62. She had presented with a fracture that was two weeks old and was advised by both areas to strap the finger, something our orthopaedic adviser and BSSH guidance say is correct. It is also the advice the Ask my GP service had given.

63. As the fracture had not bent, rotated or caused deformity to the finger, it did not require surgical intervention, with conservative management being appropriate. Mrs R was also advised to take pain relief, apply ice, keep the hand elevated and to move the finger gently.

64. Our orthopaedic adviser said moving the finger is important for the healing process as it reduces stiffness. This was recommended by both A&E and T&O, and Mrs R was given information on how to self-refer for physiotherapy.

65. From this, we have not seen any indication that the Trust (both A&E and T&O) did anything wrong in the care and treatment it provided Mrs R. It appears to have followed the correct process in assessing and treating the fracture an in the advice it gave her.

66. We have seen no indication of T&O giving conflicting advice as the letter following the virtual appointment says staff advised Mrs R to strap the finger during the appointment, but that she was not doing so, with the written advice again saying the finger should be strapped. We consider this was the same advice.

67. As such, we do not require the ICB act further in respect of this.

68. We acknowledge this will have been a worrying time for Mrs R and that she experienced pain across this period.

1. We have carefully considered Mrs R’s complaint about ​Suffolk and Northeast Essex Integrated Care Board. We are sorry to hear of her fall, resulting in a fracture to her little finger and how this has affected her.

2. Mrs R complained to ​Suffolk and Northeast Essex Integrated Care Board (the ICB) about the care and treatment provided by two organisations within its area. The first of these is a GP surgery in Suffolk (the Surgery) and the second is the Accident and Emergency (A&E) department and Trauma and Orthopaedic clinic (T&O) at West Suffolk NHS Foundation Trust (the Trust)

3. After careful consideration we have seen no indication that anything went seriously wrong in respect of the advice provided using the ‘Ask my GP’ service at the Surgery when Mrs R made contact five days after her injury.

4. We have also seen any indication that the Trust’s A&E department and T&O provided incorrect advice or treatment to Mrs R after she attended.