Wirral University Teaching Hospital NHS Foundation Trust

3. Mr X complains, because he has intractable epilepsy and does not take medication, both he and his injuries were not taken seriously. He was misdiagnosed with a sprained neck on 28 September 2024 following a fall from a high stool due to a grand mal seizure.

4. He says the Trust incorrectly advised him to do neck exercises on 28 September. He also says the Trust again misdiagnosed him with a sprained neck on 2 October.

5. Mr X says the misdiagnosis and the neck exercises prescribed by the doctors led to him:

• being unable to turn his head to the right • suffering pain when he turns his head to the left • struggling with sleep • being unable to carry out daily tasks as they are more difficult and take longer to achieve • losing his steady exercise routine to help him remain healthy • feeling distressed because the Trust staff did not take his injuries seriously.

6. As an outcome of his complaint, Mr X would like staff to be trained to treat patients with respect. He would also like the Trust’s understanding of intractable (drug-resistant) epilepsy be improved and staff training on the condition. He would also like a financial remedy of £3000.

7. Mr X has intractable (drug-resistant) epilepsy. On 27 September 2024, he fell off a bar stool in a shop due to a grand mal seizure. He continued to have a seizure. He was taken to the Trust’s A&E department by ambulance.

8. Mr X returned to A&E on 28 September where the Trust diagnosed Mr X with a neck sprain.

9. On 2 October Mr X returned to the hospital as he was in pain. The Trust took an X ray and confirmed its diagnosis of Mr X’s sprained neck.

10. On 7 October a radiologist reviewed Mr X’s X-ray and recalled Mr X to the Trust. It took a CT scan of his neck that day.

11. On 8 October the Trust informed Mr X he had a neck fracture.

12. On 5 November the spinal centre confirmed Mr X had fractures on both sides of the front part of the C1 vertebra. It treated him conservatively using a neck brace.

16. An Ambulance took him to the Trust’s A&E department. At A&E, Mr X was triaged. The records state Mr X was alert, awake and responsive during this process. Mr X claims he was not alert during the assessment. He states, usually when he has seizures, he regains consciousness in the ambulance, but this time he has no recollection of what happened during the seizure up till about 12.30am on the 28 September when he regained consciousness.

17. On regaining consciousness, he noticed A&E was busy and he saw no medics. He checked the reception and was told they could not find him in their system, so he left.

18. The discharge records on 27 September state Mr X left before a doctor could review him.

19. Mr X returned to A&E on 28 September where he gave history of the seizure. He informed the Trust he returned due to severe neck pain. He was struggling to move his neck. He felt pain on both sides of his neck, but not in the middle. He had no fever and no chest, stomach, urinary, bowel, or limb‑related sensory symptoms, and no weakness in his arms or legs. He had taken a painkiller at about 1am.

20. The records show, on examination, Mr X had no visible signs of head or neck injury. There was mild tenderness in the middle of his neck and more tenderness on the left side. He had difficulty turning his head more than 45 degrees. He also had mild tenderness over his left shoulder where he had previously dislocated it but there were no bruises or cuts. There was no tenderness over the right shoulder, chest, spine, or his hips. He was moving all four limbs normally, had full muscle strength, and could raise both legs straight up.

21. The Trust diagnosed him with a neck sprain, gave him written advice on neck injuries, went through the recommended exercises with him. It discharged him from the Emergency Department (ED) with guidance on when to return if his symptoms worsened.

22. The records show the resident doctor considered whether imaging was needed to rule out a fracture. They were guided by a senior doctor who stated Mr X likely had a sprain to his neck muscles. They advised no imaging was required.

23. On 2 October Mr X returned to the hospital as he was in pain. He informed the Trust he still had pain and stiffness in the right side of his neck. He described the pain as severe and said it made him worry.

24. On examination the Trust found Mr X to be in mild to moderate discomfort due to pain. There was no tenderness on the cervical spine (neck part of spine), but there was mild tenderness over the top of the upper back/spine. He had tenderness on the right side of the large shoulder and neck muscle, and the front/side neck muscle that helps turn and bend the head.

25. Mr X could move his neck about 45 degrees to each side, and his forward and backward neck movements were almost normal, although all movements caused him pain on the right side of his neck. He did not have any pain coming from his cervical spine during any movement. His limb neurological examination was normal, and he was able to walk normally.

26. The Trust organised an Xray, no fracture was present. On reviewing the X ray the doctor noticed rotational displacement around the first and second vertebrae but attributed that to the normal rotational effect. They believed it did not indicate a fracture and informed Mr X the diagnosis of a sprained neck was correct.

27. The Trust discharged Mr X with guidance on how to manage the sprain, telling him to return if he had any new symptoms.

28. On 7 October a radiologist reviewed Mr X’s X-ray and determined the presence of a rotational abnormality which meant a fracture could not be ruled out. As a result of this, the Trust called Mr X back in for further assessment. It took a CT scan of his neck that day.

29. The records show Mr X did not wait at the hospital for the results. The Trust called him to return to the ED the next day, which he did.

30. On 8 October the Trust informed Mr X he had a neck fracture and explained his condition to him. The Trust referred him to a specialist spinal centre and managed his fracture with a collar.

31. On 5 November the spinal centre confirmed Mr X had fractures on both sides of the front part of the C1 vertebra. It treated him conservatively using an Aspen Vista neck brace.

28 September

32. Mr X complains that due to his intractable epilepsy, the Trust did not take his condition seriously and misdiagnosed his fracture as a neck sprain.

33. NICE Spinal Guidance states anyone with a highrisk factor, such as a dangerous mechanism of injury such as a fall from more than 1 metre, should be assessed for a possible cervical spine injury. It also states spinal imaging should be carried out urgently and reviewed immediately by a trained professional.

34. The British Association of Spine Surgeons provides specialist insight that reinforces the NICE Spinal Guidance. BASS Spine Assessment emphasises a spinal injury should be assumed in all patients until it is ruled out through appropriate clinical assessment and imaging. Spinal precautions should remain in place until a spinal injury has been definitively excluded.

35. BASS Spine Assessment also lists several features that should increase suspicion of a spinal injury, and which should be documented:

36. Age and health conditions (including osteoporosis). Our clinical adviser noted people taking epilepsy medication often have reduced bone density, which increases fracture risk.

37. Mechanism of injury. Although this was not a classic highvelocity trauma, Mr X’s fall was not lowimpact.

38. Pain or neurological symptoms when sitting, standing, or walking. Mr X reported significant pain.

39. Inability to rotate the neck 45 degrees. Mr X was documented as unable to turn his neck fully.

40. Pain, tenderness, or neurological symptoms when lying flat or being logrolled. He had midline tenderness on examination.

41. Our clinical adviser also explained Mr X was a challenging patient to assess due to possible memory impairment following his seizures. This may not have been obvious to staff at the time. However, if they had recognised he was confused or unable to recall events, they should have arranged a CT scan, as a clinical examination alone would not have been reliable in that context.

42. In line with NICE guidance, the Trust should have assessed Mr X for a potential spinal injury. Although he does not take epilepsy medication and there is no evidence of osteoporosis in his history, several other highrisk features were present: a fall from height, significant pain, reduced neck movement, and both midline and leftsided neck tenderness. His fall from a bar stool could reasonably be considered a dangerous mechanism, arguably a fall from a height greater than 1 metre. Taken together, these factors clearly indicated the possibility of a spinal injury.

43. In line with NICE guidance the Trust should have carried out spinal imaging on 28 September to rule out injury, and spinal precautions should have remained in place until this occurred.

44. We cannot determine whether the Trust failed to take Mr X seriously because of his intractable epilepsy. As our clinical advice indicates, the Trust likely found it challenging to assess Mr X due to his memory impairment.

45. We find the Trust should have carried out spinal imaging to rule out injury, and spinal precautions should have remained in place until this occurred.

2 October

46. Mr X complains at this appointment he was again misdiagnosed with a sprained neck.

47. At this appointment, at Mr X’s request the Trust carried out an X-ray. The ED doctor who attended to Mr X reviewed his X-ray and reported being unable to see the first thoracic vertebrae, but otherwise there was no fracture or malalignment.

48. The ED doctor confirmed the previous diagnosis of a neck sprain was correct and discharged Mr X with guidance on how to manage his sprain; telling him to return if he had any new symptoms.

49. On 7 October, a radiologist reviewed Mr X’s X-ray and provided a report. The radiologist observed a bony part of the C1 vertebra protruded slightly compared to the C2 vertebra below it. This may have been caused by the patient’s positioning during the X-ray; however, a fracture could not be entirely ruled out based on this imaging. The radiologist recommended clinical correlation for further assessment. C1 and C2 are the top two vertebrae in the cervical spine (neck).

50. Following this report, the Trust contacted Mr X on 7 October to perform a CT scan. The scan confirmed Mr X had fractured his neck.

51. NICE Spinal Guidance states spinal imaging must be performed urgently and reviewed immediately by a trained professional.

52. RCEM ED Investigation Results states doctors typically request radiology tests in EDs and are responsible for promptly interpreting and acting on the initial results. It further states this immediate interpretation carries a risk of misinterpretation and describes a best practice called ‘hot reporting’ to reduce this risk.

53. ‘Hot reporting’ involves trained radiologists quickly interpreting certain types of X-ray films during specific hours (typically Monday to Friday, 09:00–17:00), allowing for faster diagnostic feedback.

54. RCEM ED Investigation Results also says the timing of radiology reports in EDs can vary significantly as they can be available within 10 minutes while the patient is still at the ED, or they might take up to 10 days.

55. We have seen the ED clinician attending to Mr X interpreted the initial X-ray, and a radiologist completed the final report five days later. Based on this timeline, we can see the Trust acted in line with guidance regarding who could interpret the initial report and the timing of the final report. We have not found any failings in this part of the complaint.

Neck exercises

56. Mr X says the Trust advised him to carry out neck exercises he believes caused further harm. He was unable to do the exercises because of pain and repeatedly returned to the Trust for help, spending weeks with limited movement and without a brace.

57. Our clinical adviser explained the standard management for a stable cervical injury usually involves wearing a supportive brace for 6–12 weeks to limit movement, even though it can be uncomfortable.

58. They also explained gentle neck exercises are routinely recommended to maintain mobility within the limits of pain and muscle spasm. These exercises are considered safe in both fracture and non‑fracture situations unless the fracture is unstable.

59. In Mr X’s case, the fracture was stable, meaning movement was not dangerous.

60. Our adviser explained the exercises did not worsen the fracture. They may have increased Mr X’s pain, but they would not have caused structural harm. Standard treatment for this type of injury involves adequate pain relief and gentle mobilisation, with the body naturally restricting unsafe movement through pain and muscle spasm. Only an unstable fracture would make movement unsafe, and this was not the case here.

61. There is no evidence Mr X sustained any neurological injury. He did not develop weakness, numbness, or nerve damage; his symptoms were limited to pain and stiffness. Our clinical adviser explained stiffness can arise from the injury itself, from delayed diagnosis, or simply from the natural healing process. Even if a brace had been applied immediately, long term stiffness is a recognised outcome of both the injury and its conservative treatment.

62. Taking all of this into account, we do not find any failing in the Trust recommending exercises for Mr X. Movement was clinically appropriate for a stable fracture, and any discomfort Mr X experienced was expected rather than harmful. Mr X may be reassured to know the exercises may have been painful, but they did not worsen his injury.

Impact

63. We have considered the impact of the Trust’s failure to carry out imaging on 28 September. These failings led to a delay in Mr X’s fracture being diagnosed.

64. Mr X says the Trust’s actions left him unable to turn his head to the right, struggling with sleep, finding daily tasks more difficult, and unable to maintain a steady exercise routine. Mr X said it caused him significant pain and distress.

65. Our clinical adviser explained Mr X’s symptoms were consistent with the injury itself rather than the delay in diagnosis. Our clinical adviser explained there is no evidence the delay caused long term disability. His continuing stiffness and discomfort are attributable to the injury rather than the timing of treatment, and his long-term outcome would not have been significantly different with an earlier diagnosis. The delay likely caused around two weeks of unnecessary pain.

66. While we recognise the X-ray reports were produced in line with guidance, we can still see Mr X was misdiagnosed for a time before the final CT scan on 7 October confirmed his diagnosis.

67. Had the Trust conducted an X-ray earlier, it might have prompted an earlier review. However, the Trust only performed an X-ray upon Mr X's request on 2 October, three days after the fall.

68. Had the fracture been identified earlier, Mr T would probably have been placed in a collar, given more effective pain relief, reassured, and been more comfortable. We therefore find he experienced avoidable significant pain and distress during this two-week period. The records show Mr X kept returning to the Trust due to pain, which he also described as severe.

69. Taking all of this into account, we see the Trust’s failure to carry out imaging in a timely manner caused him significant and avoidable pain and distress during the period of delay.

1. We have found the Trust failed to carry out required imaging. We have found the Trust’s actions led to Mr X experiencing significant unnecessary pain and distress. We have not seen any indications of failings in the Trust advising Mr X to carry out the neck exercises or in the time it took to interpret the imaging report.

2. We are upholding Mr X’s complaint.

70. As we have upheld this complaint these are the recommendations we are making.

71. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our Severity of Injustice Scale. Following this review, we recommend the organisation should pay Mr X £600 in recognition of the impact of the Trust’s actions on him. It should do this within one month of the date of our final report.

72. We also recommend the Trust to make service improvements to ensure it acts in line with NICE guidance by ensuring patients with a high-risk factor, such as a dangerous mechanism of injury like a fall from more than 1 metre, should be assessed for a possible cervical spine injury. The Trust should provide us with an action plan within three months of our final report detailing how and when they will make the service improvements.