Summary
C complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised to use regular simple pain relief for the shoulder injury. A was later diagnosed with a rotator cuff injury which required an operation. C said that A should have been correctly diagnosed by the doctor in A&E and that the delay left A in significant pain and distress.
We took independent advice from a consultant in emergency medicine. We found that A should have been reviewed by a senior doctor before discharge. We also found failings in relation to a lack of follow-up and record keeping. Therefore, we upheld C’s complaint.
We also found that C’s complaint was not handled reasonably as there were clear inaccuracies in the board’s complaint response and no reflection on the failings. We made a recommendation to address this.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified in this investigation in relation to the standard of care at the A&E and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .
What we said should change to put things right in future: Patients who attend the A&E with a significant soft tissue injury should be provided with a reasonable standard of medical care in relation to the referral process and follow-up.
In relation to complaints handling, we recommended: Complaint responses should be clear that failings and their impact are recognised and that any findings from the investigation are supported by the clinical records.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202310085 as a PDF (27.22 KB) Updated: March 19, 2025