Case study: Wrist injury

BACKGROUND

Ms P is out walking her parent’s dog and slips on ice, injuring her wrist. She attends a GP out-of-hours clinic and is seen by Dr R, who is working as a locum.

Dr R undertakes a careful examination of the wrist and notes a good range of movement and no particular tenderness when palpating specifically along the bone. He diagnoses wrist sprain and advises Ms P to avoid activities involving the wrist and to apply ice at intervals to reduce swelling.

The GP also suggests that a compression bandage or splint can be worn (especially at night) and over-the-counter analgesics taken to ease discomfort. Ms P is advised to attend her regular GP or the local emergency department should the pain worsen.

Over a month later Ms P is still experiencing pain in her wrist and is referred to an orthopaedic clinic. X-rays reveal a wrist fracture that has partially healed. A plaster is applied to stabilise the fracture and reduce pain and swelling until more fully healed.

A letter of complaint from Ms P is received by the out-of-hours service with details of the missed diagnosis. Dr R contacts MDDUS to ask for assistance in responding to the complaint.

ANALYSIS/OUTCOME

An MDDUS adviser comments on the draft letter of response from Dr R. In the letter the GP first expresses his regret at any inconvenience suffered by Ms P. He then offers an account of the consultation based on his notes, discussing the examination findings and the common difficulty in differentiating between a broken wrist and a strain. He states the clinical rationale for his diagnosis citing relevant guidelines.

Dr R again apologises for getting it wrong on this occasion and expresses his thanks to Ms P for informing him of the outcome – as learning points from the incident will feed into his annual appraisal and improve his practice in future. In particular, he reflects on his advice to Ms P to seek further care if the wrist pain worsens. Further examination and X-rays would also have been indicated when the symptoms did not improve over a specified period. Dr R states that in future he will be clearer and more explicit with his safety-netting advice.

The out-of-hours service incorporates Dr R’s response into a follow-up letter to Ms P and offers to meet to further discuss her concerns. The letter also states that she can refer her complaint to the ombudsman if unsatisfied that the issue has been adequately addressed. Contact details are supplied.

Ms P writes back to say she is happy with the response and gratified that her experience has served as a learning opportunity.

KEY POINTS

• An open and honest response to a patient complaint can often prevent it escalating into a claim or regulatory matter.
• Reflection on a complaint is not an admission of blame or deficient practice – rather it provides reassurance that concerns are taken seriously.
• Ensure safety-netting advice is clearly communicated to the patient – particularly when there is diagnostic uncertainty.