Manchester University NHS Foundation Trust

89. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

90. Our Principles for Remedy are reflected in the NHS Complaints Standards, which say organisations should offer fair remedies to put things right and identify learning and use it to improve services. It also states when things go wrong, organisations should give sincere and meaningful apologies and identify learning opportunities.

What we found

91. Through investigating this complaint, we found:

• the Trust misdiagnosed G’s injury • this resulted in a three-day delay in starting the right treatment, which meant G experienced worse pain than he otherwise would have during this period (the Trust has already acknowledged failings on this matter, apologised about the impact and made service improvements) • the Trust communicated poorly, giving conflicting information about whether the TENS nail would be removed or not • this caused G avoidable uncertainty and anxiety about whether he needed further surgery.

What the organisation should do

94. With these findings in mind, we recommend that following our final report the Trust writes to G to:

• acknowledge and apologise about the impact we have found in relation to the communication around the TENS nail • send a copy of this letter to us and Ms F within three months of the final report.

95.To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our SOIS.

96. Where a complaint involves different impacts, this does not add to the overall severity of injustice. Our guidance on financial remedy says we determine financial remedy based on the primary injustice. For example, where someone has experienced both pain and worry, we should refer to the relevant part of the SOIS for pain. Following this review, we recommend the Trust should:

• pay G £455 in recognition of the impact described in paragraphs 63 and 86 • send us evidence it has done this within three months of the final report.

97.Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated. This means we ask that the Trust:

• produces an action plan to address the failings relating to the poor communication • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who was responsible, the timescale for completion, and how it will be/was monitored • share the action plan with us, G, NHS England (NHSE) and Care Quality Commission (CQC) within three months of the final report • share a copy of our final report with NHSE and CQC at the time it shares its action plan with these organisations.

7. Ms F complains about the care and treatment her son, G, received when he presented with a broken arm at the Trust in January 2024. She specifically complains that the Trust did not scan the correct part of G’s arm despite the triage nurse telling Ms F they would request X-rays for his arm. She says the Trust misdiagnosed G’s injury.

8. She also complains the Trust communicated poorly, giving conflicting information about the type of treatment and its duration.

9. Ms F says the incorrect imaging and misdiagnosis meant the Trust did not give G effective pain management. She says G still experiences ongoing physical side effects including lack of flexibility in his arm and the loss of sensation in it when writing for more than 30 minutes. She says this put additional stress on G when sitting his GCSEs. One of G’s GCSEs was Physical Education (PE) and he was unable to do the practical part of his exam, which meant he could not get a higher grade.

10. Ms F also tells us G’s mental health declined as he was unable to do his school work or take part in sporting activities, which were a large part of his life and identity. She says G’s school were so concerned about the impact on his mental health, it made a referral to an early intervention team to work with him.

11. She tells us the poor communication caused G distress because there was a lack of certainty about whether he would need ongoing operations or not. She says G was left feeling very anxious about his chances of returning to sports, which were a huge part of his social life.

12. Ms F wants the Trust to acknowledge its failings and the impact the failings have had and continue to have on G. She is seeking service improvements and a financial remedy.

13. G attended A&E at the Trust on 9 January 2024. He had sustained an injury to his arm playing basketball.

14. The A&E nurse in triage identified possible fractures to his ulna, radius and wrist. Staff later performed an X-ray on his wrist. Based on the results, they considered G had sprained his wrist.

15. When Ms F raised her concerns about the accuracy of the diagnosis and use of a wrist splint, a doctor used a mini-ultrasound (Point of Care Ultrasound Scanning – POCUS) attached to their mobile phone to look at G’s lower forearm. The doctor did not change their diagnosis following this examination.

16. On 12 January when G’s pain had not improved, Ms F noticed his arm was still swollen and was hot to touch. They returned to A&E and an X-ray showed a non-union fracture of the radius which needed urgent surgery.

17. That evening, G had his arm plastered and the consultant said the X-rays done on 9 January were only of half his forearm and missed a clear non-union break to his radius by a centimetre. The consultant explained G would need either a TENS nail or plates and screws in his arm.

18. The consultant said the TENS nail would need taking out (so another surgery) and the plates and screws would be permanent. They said there would be no difference in result.

19. When G went in for his surgery (16 January 2024) the surgeon said the TENS nails could be left there permanently.

20. A few weeks after the operation, G received a letter saying the Trust would remove the TENS nail in six months’ time. At the next follow-up appointment, the doctor told him it would stay in permanently.

Point one: the Trust did not scan the correct part of G’s arm

23. Ms F complains the Trust failed to scan the correct part of her son’s arm despite the triage nurse telling Ms F they would request X-rays for his forearm. Ms F says the triage nurse verbally communicated they suspected a break to G’s radius and ulna in his forearm.

24. The Trust explains in its 12 September 2024 response, that at triage, G had a deformity on his right wrist, thought to be a fracture. The triage nurse then ordered a wrist X-ray. The Trust explains this was based on examination and G’s symptoms at the time.

25. The records show at 4.18pm on 9 January 2024, the triage nurse ordered an X-ray of G’s right radius and ulna. At 4.42pm, the triage nurse modified the request to ‘XR wrist right.’ At 4.51pm the records indicate the imaging of just G’s wrist had ended.

26. Ms F highlighted the above records to the Trust on 6 November 2024 in response to the Trust’s letter dated 12 September 2024.

27. On 10 March 2025, the Trust provided Ms F with a second response to her complaint. In it, the Trust admits the triage nurse’s original area of interest was the right radius and ulna (forearm) and this was the area for the X-ray the triage nurse ordered.

28. The Trust explains prior to an X-ray, radiographers are required to justify the associated dose of radiation under the national ionising radiation (Medical Exposures) regulations. This meaning the radiographer checks the information given by the referrer and may adjust the area under investigation. It says this is done to ensure the patient is not receiving an unnecessary dose of radiation. It also states the requests from the Paediatric Emergency Department (PED) are usually quite broad and need adjusting.

29. In its investigation of Ms F’s complaint, the Trust recognise the triage nurse did not justify the request for a forearm X-ray and the radiographer should have clarified the written information on the request with G prior to the imaging.

30. The Trust apologises for its oversight. It states it will feedback to the wider nursing team about the importance of specific detail being added to an X-ray request to ensure radiology have adequate information to complete an X-ray.

31. The Trust acknowledges that by carrying out an X-ray on G’s right wrist, rather than his full forearm, this led to a delay in diagnosing and managing the fracture in his forearm. The Trust apologises for this and the impact this had on G.

32. We considered what should have happened.

33. Our radiographer adviser explains it is not appropriate to expose anyone to ionising radiation, for example, through doing an X-ray, without clear indication. If there is no supporting information with an X-ray request from colleagues, radiographers cannot justify the exposure to the patient.

34. We appreciate this means radiographers should avoid doing unnecessary X-rays, or scan only the area of the body they need to. They are guided on what scans to perform based on the requests they receive from colleagues, and the information colleagues provide to justify doing scans.

35. Based on the available evidence, we concluded the triage nurse recognised a potential fracture was not in the region of the wrist but higher in G’s arm. Their initial triage of G and radiology request reflected this.

36. The nurse later modified this and requested that radiographers X-ray G’s wrist. As the Trust acknowledged, the nurse did not provide information to justify scanning the area other than his wrist. This meant the radiographer did not have sufficient information to justify exposing G to a higher dose of radiation by X-raying the full arm. Based on the information the radiographer had, they X-rayed his wrist.

37. Our A&E adviser said this meant the X-ray staff performed was not sufficient to assess G’s injury. It did not cover the whole area of his arm where staff had suspicion about a break. This meant it did not detect the break staff later saw in his radius on 12 January.

38. Section seven in Good Medical Practice says clinical staff should promptly arrange suitable investigations to assess a patient’s condition. Having considered the above, we see the Trust did not arrange suitable investigations for G’s injury when he attended A&E.

39. Additionally, Ms F tells us after doctors shared the outcome of G’s injury post X-ray, she was not confident it was correct. She says she raised this with staff and a doctor carried out a portable ultrasound scan (POCUS) on G’s lower forearm. She says she specifically told the doctor her concerns were about his upper forearm.

40. The Trust says a full examination of G’s arm should have been performed yet also states the imaging was based on G’s presenting symptoms and the previous wrist X-ray. It apologises that this further imaging of G’s forearm missed the upper forearm fracture. It also states the doctor who did the POCUS has reflected on the scope of practice with POCUS and has had additional training on its use.

41. Given Ms F raised these concerns to the doctor, we also saw staff missed a further opportunity to do suitable investigations to assess G’s forearm.

42. Considering all the above, we saw evidence the Trust did not scan G’s full forearm on 9 January 2024. This was despite his records indicating the triage nurse initially requested an X-ray of G’s right radius and ulna and they suspected an injury in this area. We find this was a failing. We give our views about the impact this had from paragraph 52.

Point two: the Trust misdiagnosed G’s injury

43. Ms F says the Trust misdiagnosed G’s injury on 9 January 2024. She says she was concerned about the swelling G had above his wrist. She also tells us she had shared her concerns initially with the triage nurse and this is why the triage nurse initially requested an X-ray of G’s ulna and radius.

44. Ms F tells us she became increasingly concerned about the swelling on G’s forearm over the following few days. This meant they returned to A&E on 12 January 2024. A different doctor saw G and ordered an X-ray of his right ulna and radius, which showed ‘a transverse fracture at the proximal third of the radius’ (a fracture on G’s forearm nearest his elbow).

45. In its response from 12 September 2024, the Trust said the doctor during G’s first A&E visit reflected on their diagnosis. It explains they mistakenly focused on identifying a wrist injury as they understood this was the area of concern for G.

46. It explains it is the doctor’s responsibility to re-examine and consider whether the correct X-ray was performed and to arrange additional views based on a more detailed history and examination than the initial diagnosis in triage.

47. The Trust apologises for not making the correct diagnosis on this occasion and apologises for any distress Ms F and G experienced.

48. Good Medical Practice, sections six and seven, say doctors must provide a good standard of practice and care to patients, working in partnership with them to assess their needs. In providing good clinical care, the guidance states doctors must adequately assess a patient’s condition, taking into account their history, symptoms, patient’s view and where necessary carry out a physical examination.

49. Based on the evidence, we found the Trust failed to make the correct diagnosis for G’s injury on 9 January 2024.

50. As we explained in paragraphs 24 to 26, the first explanation for this is that the Trust did not arrange the right scans to assess G’s injury. They did not review all the injured area. This meant the scans staff performed could not detect the break in G’s radius.

51. Had Trust staff taken into account Ms F’s and G’s views and re-examined G following the nurse’s initial diagnosis in triage, the Trust could have taken the appropriate steps to correctly diagnose G’s injury. We saw they continued to raise concerns about pain and swelling G had above his wrist. We find this was a failing.

Impact of point one and two

52. Ms F tells us the misdiagnosis meant G was not given effective pain management. She tells us G still experiences ongoing physical side effects including lack of flexibility in his arm and the loss of sensation in it when writing more than 30 minutes at any one time. Additionally, Ms F tells us G was sitting his GCSEs at the time, and this caused him additional stress.

53. To understand the impact this failing had on G, we asked our orthopaedic adviser if G’s recovery would have been any different without the three-day delay in treatment from 9 January to 12 January 2024.

54. Our adviser said if the fracture was displaced at the time of the injury, the path to recovery would have been the same. They explain the wrist splint (which staff fitted because they considered G sprained his wrist) would not have caused more damage but would have meant G was still in pain as the wrist splint was not supporting the fracture.

55. We consider, on the balance of probability, the fracture was displaced on 9 January 2024. This is because there is evidence from the A&E triage notes to suggest G was experiencing symptoms in his forearm bones (the ulna and radius) as well as his wrist.

56. This is consistent with what Ms F has told us. She tells us she could see swelling above the wrist splint. This would indicate displacement.

57. We also asked our adviser if there were indications that G would have had a better clinical outcome had his injury been assessed and treated on 9 January 2024 as opposed to 12 January 2024. We asked our adviser to specifically comment on G’s loss of sensation when writing for prolonged periods of time and lack of flexibility.

58. Our adviser explains fractures and the TENS nail surgery have an association with nerve injury and there is likely to be scar tissue following the surgery. They explain this can cause a loss of sensation. They also explain the loss of flexibility in G’s arm is most likely from the injury itself. It is therefore more likely to be trauma related rather than from the three-day delay in treatment.

59. Good Medical Practice states doctors should promptly provide suitable advice, investigations and treatment. Once G had returned to the Trust on 12 January 2024, Trust staff did promptly act on his and Ms F’s concerns and carried out the appropriate investigations and treatment for G’s symptoms.

60. We appreciate Ms F feels the delay of three days from 9 January to 12 January caused significant harm to G.

61. Based on the evidence available to us and using a balance of probability, it is likely that if G’s injury was correctly diagnosed on his first visit to A&E then the surgery would likely have been three days earlier. We therefore consider the delay in G receiving the correct care and treatment amounted to three days.

62. In this time, he did not have the correct splint to support his fracture to help manage the pain associated with this injury. This means, we saw G experienced three-days of pain that would have been worse compared to a scenario where staff provided the correct management from 9 January.

63. As G’s injury itself, rather than any delay in care seems to explain the loss of sensation and flexibility in his arm, we cannot link these impacts to the failings Ms F alleges. This means we cannot link the further emotional and mental health impacts she describes in paragraph nine and ten to the failings we have found.

64. As we identified failings and an impact, we considered what the Trust has done to address this. We note Ms F wants the Trust to acknowledge any failings and the impact they had. She also wants it to make service improvements. These are things our Principles for Remedy recommend the Trust should do.

65. As we have highlighted at various points in our analysis from paragraph 27, the Trust has acknowledged the same omissions we found and the impact they had during its complaint process. We also saw it arranged reflective or training actions for the staff involved.

66. Our Principles for Remedy say these are appropriate actions to try and prevent a repeat of any mistakes. So, we cannot see there is more the Trust should do regarding these outcomes.

67. Our Principles for Remedy also say we aim to ensure the public body puts the aggrieved back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

68. We appreciate Ms F also seeks financial remedy. Based on our Severity of Injustice Scale (SOIS), in our guide on financial remedy, we view the impact we saw to sit at level two in our SOIS. This is because the Trust did not identify G’s fracture for three days, which led him to experience worse pain during this period than he otherwise would have had.

69. According to our SOIS, level two impacts include when a patient experiences severe avoidable pain lasting no more than one week. This is pain which needs more than nonprescription pain relief to manage.

70. As our orthopaedic adviser identified G should have had a cast to support his fracture to help with his pain, we consider this measure goes beyond non-prescription medication. This means we consider it was severe pain G experienced, and a level two impact.

71. In these circumstances, our SOIS suggests an organisation should pay a financial remedy of between £120 and £550. This is not something the Trust has done. Therefore, we consider it should take this action to address this impact. We explain this recommendation further from paragraph 89.

Point three: the Trust communicated poorly, giving conflicting information about G’s treatment

72. Ms F says throughout G’s care and treatment following on from 12 January 2024, they were given conflicting advice regarding the surgery options for G. She says this led to confusion and made G anxious.

73. She says they were initially told the TENS nail in G’s arm would need removing, which involved a second surgery. She says she was then told by the surgeon on the day of the surgery (15 January 2024) the TENS nail could be left there permanently.

74. A few weeks after the surgery, the Trust sent G a letter (dated 12 February 2024) to attend a clinic to check on his arm. This letter stated the TENS nail would be removed in six months’ time. At the appointment on 22 March 2024, the doctor said the TENS nail would remain permanently.

75. In its response on 24 September 2024, the Trust apologises for the conflicting information regarding the removal of the TENS nail. It says being seen by a different clinician each time contributed to the inconsistency.

76. The Trust sought input from two orthopaedic surgeons who shared the same opinion that the TENS nail would not need removing providing it did not cause any symptoms or concerns for G.

77. Section 30 in Good Medical Practice says clinicians must make sure they give patients clear and accurate information about their condition.

78. From the evidence, we view the Trust failed to provide clear advice and information on whether the TENS nail would be permanent or temporary requiring a further operation to remove it. It has acknowledged staff gave conflicting information on this matter.

Impact of point three

79. Ms F tells us the conflicting information about the TENS nail caused G a lot of anxiety about whether he would need to have ongoing operations or not. Further operations would mean G would be unable to return to sports sooner and this caused him a lot of anxiety as sports is a large part of G’s identity and social life.

80. We appreciate how important sports is to G and how unsettling this time was for him.

81. We sought advice from our orthopaedic adviser about the impact Ms F explained to us. Our adviser explained the uncertainty of whether the metal work would come out or not could cause anxiety. They further explain there would always be a degree of uncertainty about when G could return to sports as this would depend on the injury itself and how the treatment worked. If the metal work was removed, our adviser explained G would need to stop sports for six weeks before returning.

82. We can understand the conflicting information contributed to the anxiety Ms F has told us. We can on a balance of probability, say G did experience some degree of anxiety around the lack of clarity about whether an operation was needed.

83. G had his operation on 15 January 2024 where he was told the TENS nail would be permanent. He was then told on 12 February it would need to be removed before being told on 22 March it would be permanent. This conflicting information caused G anxiety for a period of two months.

84. The Trust could have provided clarity about G’s operations at an earlier stage. This meant it could have avoided the anxiety and uncertainty G experienced on whether he needed to undergo further surgery.

85. Ms F says G was still anxious about whether the TENS nail would be removed or not after the appointment on 22 March. It was only when Ms F raised the complaint to the Trust that she and G received clarity on the conflicting advice. The Trust’s response was 12 September 2024. This is a total period of nine months where Ms F and G lacked certainty in whether G would need to undergo further surgery.

86. The Trust has apologised for the poor communication G received following the conflicting advice from different consultants. It has not acknowledged the impact this has had on G or made service improvements. This is something our Principles for Remedy indicate the Trust should do.

87. Based on our SOIS, we view this impact would sit at level two, which indicates a financial remedy. The financial remedy at this level refers to distress and worry of which a healthy adult would be expected to deal with. The emotional impact would be expected to lesson completely in the fullness of time.

88. We consider this period was worrying for G. We believe the Trust resolved this worry after it gave clarity on the conflicting advice he received. We give more details about the financial remedy we are proposing in our recommendations section.