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Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.2137/01-02
Complaint against East Kent Hospitals NHS Trust
Summary of Case
Mrs W broke her wrist. She attended the A&E department at Kent and Canterbury Hospital and was told that she had a Colles fracture (a break at the lower end of the radius which produces a 'dinner fork' deformity). She attended the fracture clinic 6 days later, and was told that the fracture was unstable and would have to be ‘pinned’ (or K-wired). The operation was planned for that weekend, but when Mrs W telephoned to confirm that a bed would be available, she was told that there was a bed shortage and her wrist would not be pinned that weekend. The following Monday, she was told that a consultant orthopaedic surgeon (the first surgeon) and an orthopaedic registrar had reviewed her X-rays and decided against K-wiring; Mrs W’s plaster was replaced. The plaster was replaced again a week later, following a further X-ray. When the plaster was removed, Mrs W’s arm looked ‘odd and swollen’, and she was unable to turn her wrist. During physiotherapy, her arm became painful; the fracture was then found to have mal-united. Mrs W felt that the bed shortage had influenced the decision not to K-wire her wrist. In June, Mrs W was referred to another consultant orthopaedic surgeon (the second surgeon), for corrective surgery. Mrs W was told that the second surgeon intended to operate on both forearm bones (the radius and the ulna). However, on the day of the operation he decided to operate on the ulna only. This concerned Mrs W as her undamaged bone was now broken and she felt the operation was unsuccessful. In November, the second surgeon discharged Mrs W from his care, saying that he was unable to do anything more for her; Mrs W was left with a deformed wrist.
Findings
The Ombudsman took advice from two independent professional assessors. The Ombudsman was unable to establish who made the initial decision to K-wire the fracture as there were insufficient records; she criticised the Trust for that. The Ombudsman also could not establish precisely when the first surgeon decided that K-wiring was not necessary. However, she was satisfied that that was a clinical decision and not due to a bed shortage. The assessors said that by the second time the plaster was replaced, the fracture had slipped, and at that point it should have been K-wired. The assessors also felt that the second surgeon’s failure to operate on the radius was an error of judgment, and that the correct procedure would have been an operation to divide and realign the radius (an osteotomy), as well as the removal of a segment of the ulna. The Ombudsman upheld the complaint that the management of Mrs W’s fracture was inadequate.
Remedy
The Ombudsman recommended that the Trust ensure that any changes to proposed surgery, including instances where there is more than one option and the decision is to be taken while the patient is under anaesthetic, should be noted on the original consent form and signed by the surgeon and the patient. She also recommended that the lack of record-keeping be addressed. The Trust agreed to these recommendations and apologised to Mrs W for the shortcomings identified.
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