Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
The man sustained two fractures in his left femur in an accident, which required two surgeries. After the surgery, the man was transferred to another hospital and placed under the care of a different orthopaedic surgeon. He was discharged from hospital after three months with a plan for follow up at an outpatient clinic to assess the healing progress.
The man struggled with pain and difficulty moving. An x-ray was taken at the first outpatient appointment, which did not show convincing evidence that the femur was healing. The man was unable to attend his second appointment in person, and a third appointment took place two months after the first. By that stage, the man was still in significant pain and his range of movement in his leg had decreased, and he was booked in for a procedure to realign his kneecap. The orthopaedic surgeon did not order any further imaging at the third appointment.
Six months after he was discharged from hospital, the man’s physiotherapist ordered further x-rays, which showed the fracture had not healed and the man underwent further surgery.
Ms James found the supervising consultant had failed to arrange further investigation of the man’s prolonged pain, which resulted in a delay in identifying that his femur had not healed properly. She also found the surgeon had failed to document a care plan regarding the man’s femur.
“As the supervising consultant, it was the orthopaedic surgeon’s responsibility to arrange this further investigation,” says Ms James.
“In the context of a delayed union and the fact that the man was presenting with pain on weight-bearing, the management plan should also have included consideration of the possibility of an evolving non-union,” says Ms James.
Ms James recommended the doctor provide a written apology to the man, advise HDC how he intends to ensure he has appropriate peer/collegial support available to him for consultations on complex orthopaedic cases, and record a management plan in any future cases where there is a suspected delay in bone healing.
This case relates to a complaint made to HDC in 2019. We aim to investigate complaints as promptly as possible, while ensuring natural justice and the interests of all the parties involved to provide information, and respond to evidence put forward by others is considered.
Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name Te Whatu Ora (previously DHBs) and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here.
