NHS Tayside has been advised to apologise to a patient who ended up in constant pain after a nurse practitioner in Perth apparently failed to record they had fractured their wrist during a fall.
The Scottish Public Services Ombudsman (SPSO) said the board ought to apologise to the patient after investigating their complaint and establishing the mistake contributed to them suffering continuous pain and losing the function of their wrist.
A written ruling published by the body this week said the patient attended Perth Royal Infirmary ’s accident and emergency department and was sent for an X-ray.
The decision notice, which referred to the complainer only as C, said: “In relation to C’s initial attendance at A and E where they were seen by a nurse practitioner (NP), we found that the NP recognised from their clinical assessment that C may have sustained a fracture to their wrist and appropriately had the wrist X-rayed.
“However, it was recorded in C’s clinical notes that the X-ray showed no bony injury, which indicated the NP had wrongly interpreted the X-ray as being normal.
“However, the discharge letter from A and E to C’s GP stated a different diagnosis suggesting that the fracture was identified.
“We only received an explanation from the board for the conflicting diagnoses, which was that the NP had made a mistake in recording there was no bony injury, at a late stage in our investigation.
“We noted that the treatment the NP provided to C in referring them for an X-ray and making a referral to the virtual fracture clinic was appropriate.
“We found that the doctor who later reviewed C’s case at a fracture clinic correctly identified that C had sustained a fractured wrist.
“However, the board accepted that C should have been referred to see an orthopaedic consultant at an earlier stage. We noted that the board had apologised to C for this and taken action to address what occurred.
“Finally, we found that given C’s medical history and their significant medical co-morbidity, it was reasonable to take a conservative approach and to not perform surgery at the time.
“Taking into account all of the evidence and the advice we received, on balance, we upheld C’s complaint.”
The decision notice indicated patient C is still awaiting surgery to relieve the pain in her wrist and restore its function.
An NHS Tayside spokeswoman said: “We are sorry that treatment and care in this case fell below the standard we would expect.
“We have actioned all the recommendations in the report and have apologised to the patient.”
