Source · SPSO (Scottish Public Services Ombudsman)

Greater Glasgow and Clyde NHS Board - Acute Services Division

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 201902479 Sector Health Category clinical treatment / diagnosis Decided 01 October 2020

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Full decision

Summary

C complained on behalf of their client (A) who was admitted to the Royal Alexandra Hospital after fainting at home. A CT scan showed that A had suffered a fractured bone in their neck. A was initially fitted with a collar but C complained that this did not fit well and caused A severe pain and discomfort, to the extent that A's neck injury became worse. Due to A's ongoing pain, a further CT scan was carried out which confirmed that the fracture had displaced (not lined up) slightly. A was referred to the spinal unit at another hospital and was fitted with an alternative form of brace. C complained that A should have been referred to the spinal unit from the outset.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We considered that the initial investigations and treatment were reasonable. We found evidence that the fitting of the collar was checked by staff. We also considered that the subsequent change to an alternative brace was reasonable, and there was no indication for an earlier referral to the spinal unit. However, we were critical of a delay in reporting the second CT scan. This was an urgent scan which should have been reported within days, but it was not reported for three weeks. This delay did not cause A harm, but it did prolong their pain and discomfort. The treatment of A's injury was otherwise of a good standard and, on balance, we did not uphold this complaint.

Related reading

View Decision Report 201902479 as a PDF (24.5 KB) Updated: October 21, 2020

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