Just a sprain

BACKGROUND

A 15-year-old girl – Beth – twists her knee playing football for her local club. Her mother – Mrs N – is called and brings Beth to A&E. Here she is seen by a specialist registrar Dr U. The doctor examines Beth and notes pain and mild swelling. Beth displays a good range of movement and there is no obvious deformity or neurologic symptoms.

Dr U sends Beth for an X-ray which reveals no evidence of bony injury. She advises Beth and Mrs U that it is likely “just a sprain”. She provides Beth with a Tubigrip and advises rest and over-the-counter analgesia. Should there be no improvement in the next few days she advises that Beth attend her own GP for further investigation.

Later that night the pain grows worse and the next morning Beth cannot walk unaided. Mrs U makes an emergency appointment with her GP – Dr L. He is concerned that Beth may have damaged a ligament and, at Beth and Mrs U’s request, refers Beth to a private orthopaedic surgeon.

An appointment is arranged for the following day. The surgeon examines the knee and an MRI is arranged which shows an anterior cruciate ligament (ACL) tear. Beth is placed on crutches and prescribed physiotherapy in advance of ACL reconstruction in three to four weeks when the swelling is reduced.

The surgeon expresses “surprise” that the diagnosis was missed in A&E and that there was no onward referral to an on-call orthopaedic specialist.

A week later the hospital receives a letter of complaint from Mrs U in regard to her daughter’s treatment in A&E. She is critical of the decision to send Beth home without a referral, considering it might have further damaged her knee.

ANALYSIS/OUTCOME

Dr U is required by the hospital to make a statement regarding her care of the patient and contacts an MDDUS adviser for guidance on the wording.

The adviser first reminds Dr U that when responding to a complaint made by a third party it is essential to obtain the patient’s consent prior to doing so. Beth at age 15 may be considered competent to provide such consent and Dr U is encouraged to confirm with the hospital complaints officer that this has been secured.

She is advised to open her statement with an acknowledgement of the family’s dissatisfaction with the care given and regret for the pain and inconvenience suffered. In her response Dr U is reminded to highlight the source of any information given, for example it might be from review of the contemporaneous medical records, her recollections of events, discussions with colleagues or referring to her usual practice.

In particular the statement should include the justification behind Dr U’s conclusions from her assessment. In describing this, Dr U should include the relevant positive and negative findings that support her diagnosis of a sprain and explain how she excluded any ligament damage. She should also explain why a referral was not indicated at this stage. The records state that the patient managed to walk into A&E and a little more detail on this point could be helpful.

The MDDUS adviser then reviews the statement before it is returned to the complaints officer. Nothing more is heard from the complainants and the case is closed.