Barts Health NHS Trust (P-001026)

  • 1.	We have identified a failing in the Trust not taking all reasonable steps to reduce the risk of the complainant falling over the weighing scales on 30 January 2018. We cannot say that the fall caused the damage to the complainant’s right shoulder seen on the X-ray. This is because the X-ray showed osteoarthritis and calcification which are more likely to have been pre-existing conditions and are unlikely to have developed suddenly. 
    
    2.	However, we appreciate the fall itself is likely to have been painful and may have aggravated the complainant’s existing arthritis and calcification and may have led to an earlier onset of the complainant’s ongoing pain. While we appreciate that the Trust has acknowledged the complainant’s fall and moved the scales out of the way following the complainant raising concerns about them, we think more could be done to acknowledge the impact the incident has had on the complaint. Therefore, our decision is we partly uphold this part of the complaint. 
    
    3.	We recommend by Monday 16 November 2020 the Trust apologises to the complainant to acknowledge the pain that the fall has caused them. We recommend that by Monday 11 January 2021 the Trust provides us with evidence that staff are aware of their responsibilities according to the policy. The Trust should also send an anonymised copy of our final report and evidence of the action that the Trust has taken to address the failings to the Care Quality Commission and NHS Improvement.
    
    4.	There was a failing in the Trust not arranging for a doctor to review the complainant after their fall and before they went home. There was also a failing in the Trust’s lack of communication with the complainant’s GP and poor record keeping following the fall on 30 January 2018. We cannot say that if the Trust had arranged for a doctor to review the complainant and promptly informed their doctor of the fall they definitely would have experienced less pain or increased mobility but they missed the opportunity to ever know whether their situation would have been better. 
    
    5.	However, if the Trust had provided appropriate after care the complainant is likely to have received pain relief, physiotherapy and may have had an X-ray earlier, and may have been considered for support at home. We also recognise that it will have been distressing for the complainant to believe the Trust did not care for them as it should have done. We appreciate that the Trust has acknowledged the complainant’s fall was not correctly recorded, reminded staff of the importance of documenting events as well as acknowledging that the complainant should have had a medical review. However, we think the Trust could have done more to acknowledge the impact the incident has had on the complainant. Therefore, our decision is we do partly uphold this part of the complaint. 
    
    6.	We recommend that by Monday 16 November 2020 the Trust apologises to the complainant to acknowledge how the Trust not giving the complainant medical attention at the time of his fall may have meant that there was a delay in the complainant’s pain being addressed and a missed opportunity for possible further support. 
    
    7.	We recommend that by Monday 11 January 2021 the Trust tells the complainant and ourselves what action it has taken to ensure that Datix reports are created at the time of incidents in the future. 
    
    8.	We also recommend that by Monday 16 November 2020 the Trust should pay the complainant £500 in recognition of the pain the complainant experienced due to the fall itself and the pain the fall appears to have triggered and the missed the opportunity to access pain relief and physiotherapy earlier along with the possibly to be considered for support at home earlier all of which could have potentially resulted in a better overall outcome for the complainant. 
    
    9.	We have not seen evidence to conclude that the Trust received or ignored the complainant’s earlier complaint letters sent before May 2018. Therefore, our decision is we do not uphold this part of the complaint.
    
  • 10.	The complainant complains about a fall they had at the Trust in January 2018. They say they attended an appointment and then after leaving the consultation room to get blood tests, they fell over some scales that the Trust had placed in a dangerous place in the corridor. They say the Trust took their blood pressure and then told them they were free to go, without doing any other checks to make sure they had not hurt themself. They also complain the Trust informed them their GP would be made aware of the fall, but when they went to see their GP a week later their GP had no idea it had happened. They complain an X-ray revealed they had seriously damaged their shoulder and they needed to pay someone to come help them wash and dress for eleven weeks at a cost of £1300.
    
    11.	The complainant also complains about the Trust’s complaint handling. They say they complained to the Trust a couple of days after the fall but this, and their subsequent two further letters of complaint were ignored. They say they only got a response four months later when they sent a letter via recorded delivery to the Chief Executive. 
    
    12.	The complainant says the fall has changed their life. They are unable to put weight on their arm or pick things up without shooting pains in their shoulder, and they are now unable to bathe and must wash standing up in the kitchen. They found the lack of care by the Trust very distressing.
    
    13.	As an outcome to their complaint the complainant would like an apology and reimbursement of the £1300 they spent.
    
  • 14.	The following brief background is to place the complaint into context. We do not intend the background to be detailed, as all parties are aware of the information surrounding these events.  
    
    15.	On 30 January 2018, the complainant attended Royal London Hospital for an appointment. The complainant fell over weighing scales in the corridor of the department after their appointment and they injured their right shoulder.
    
    16.	The complainant told us they tried putting oils and heat packs on their shoulder but the shoulder pain was getting worse so on 29 March 2018 they visited their GP who requested an X-ray of the complainant’s right shoulder and prescribed them piroxicam gel (non-steroidal anti-inflammatory drugs used to relieve pain in joints and muscles when rubbed into the skin).
    
    17.	On 12 April 2018 the complainant had the X-ray which did not show any bone fractures by noted mild osteoarthritis of the joint at the top of their right shoulder and calcification (calcium deposits) around the muscles at the top of their shoulder.
    
    18.	To address the complainant’s shoulder injury on 24 April 2018 their GP referred them for physiotherapy and prescribed them co-codamol (a mixture of two different painkillers - paracetamol and codeine used to treat pain).
    
    19.	During an appointment with the Trust on 28 August 2018 the complainant explained that they were still experiencing pain in their right shoulder following their fall in January. The Trust offered to refer the complainant to an orthopaedist (a doctor who treats bone abnormalities) or a rheumatologist (a doctor who treats issues with the muscles and bones) for consideration for intra-articular injections (injections in the joint to relieve pain). The complainant declined the offer of this referral.
    
  • 20.	The evidence we have considered includes the complainant’s account of what happened, the complainant’s clinical records and the complaint file from the Trust.
    
    21.	We also obtained advice from a consultant orthopaedic surgeon (our clinical adviser) who has over 20 years’ experience. 
    
    22.	We use related or relevant law, policy, guidance, and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the following standards:
    
    •	Barts Health NHS Trust, Adverse Incident and reporting policy, March 2015 https://www.whatdotheyknow.com/request/387389/response/947650/attach/4/FOI%20088%2017%20BH%20Adverse%20incident%20policy.pdf?cookie_passthrough=1
    •	General Medical Council (GMC), Good Medical Practice, April 2013 https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1---knowledge-skills-and-performance#paragraph-19
    •	Health and Safety at Work Act 1974, https://www.legislation.gov.uk/ukpga/1974/37/section/3
    •	Healthline, What Causes Calcific Tendonitis and How Is It Treated? https://www.healthline.com/health/calcific-tendonitis#symptoms
    •	NHS, Osteoarthritis https://www.nhs.uk/conditions/osteoarthritis/
    •	Patient, Osteoarthritis https://patient.info/bones-joints-muscles/arthritis/osteoarthritis
    •	Parliamentary and Health Service Ombudsman, Our guide on financial remedy https://www.ombudsman.org.uk/sites/default/files/Our-guidance-on-financial-remedy-1.pdf 
    •	Regulation 3, The Management of Health and Safety at Work Regulations 1999 https://www.legislation.gov.uk/uksi/1999/3242/regulation/3/made
    •	Regulation 12 (3), The Workplace (Health, Safety and Welfare) Regulations 1992 https://www.legislation.gov.uk/uksi/1992/3004/regulation/12/made
    
  • Fall
    
    23.	On 30 January 2018 when the complainant was leaving a consultation room at the Royal London Hospital, they fell over weighing scales which the Trust had placed in the corridor outside the consultation room. The complainant said they walked out of the consultation room, turned left and then felt like someone had grabbed their legs and threw them to the floor. 
    
    24.	The Trust has acknowledged the complainant’s account and has not disputed their recollection of the incident. 
    
    25.	The law on health and safety requires organisations to take action to prevent employees, visitors and members of the public from hazards which may cause someone to slip, trip or fall over.  This includes carrying out risk assessments to consider how to reduce the risk of falls  and ensuring that people can walk around their building safely free from obstructions. 
    
    26.	In line with health and safety law we would expect the Trust to take every reasonable step to reduce risk of harm by falling. We would expect the Trust not to leave items in locations that could cause someone to fall over them or to warn people of the danger with for example, a warning sign. Therefore, our decision is by placing the weighing scales in the corridor there has been a failing in the Trust not taking all reasonable steps to reduce the risk of the complainant falling over them on 30 January 2018. 
    
    27.	The complainant says an X-ray revealed the fall had seriously damaged their shoulder and they needed to pay someone to come help them wash and dress. 
    
    28.	The X-ray shows the complainant has mild osteoarthritis of the joint at the top of their right shoulder and calcification (calcium deposits) around the muscles at the top of their shoulder. Our clinical adviser told us it is likely that these issues were there for a long time but without any symptoms and were not caused by the complainant’s fall but have been found incidentally on the X-rays. However, the fall itself may have worsened these conditions which may have led to at least an earlier onset of their ongoing pain the complainant began to experience.
    
    29.	Our understanding is that osteoarthritis is a long-term condition which cannot be cured. It is where the protective layer of cartilage at the end of your bones is worn down and this can cause pain, swelling and difficulty moving the joint. While a joint injury can lead to osteoarthritis this usually only happens a long time after the injury if the joint is not given enough time to heal.   Symptoms usually develop gradually and some people have osteoarthritis may not have any symptoms.  
    
    30.	Calcification is where calcium builds up in the muscles or tendons making moving the joint difficult and it can cause pain. Similarly, with osteoarthritis, some people with calcification do not experience and symptoms but pain may start suddenly. 
    
    31.	We are not persuaded that the complainant’s fall caused their mild osteoarthritis and calcification as they appear to be more likely to have been long term conditions and are unlikely to have developed suddenly. However, we note that the complainant had not reported experiencing shoulder pain before their fall on 30 January 2018. So, the Trust’s failing to take all reasonable steps to reduce the risk of the complainant falling led to the complainant’s fall. It is likely the fall was painful, and the fall may have aggravated the complainant’s pre-existing osteoarthritis and calcification causing at least an earlier onset of their ongoing pain. This may have resulted in the complainant starting to experience pain in their shoulder. We recognise that the complainant may have had difficulties with their daily tasks such as bathing and dressing due to the pain and that this may have required help with their personal care. 
    
    32.	While we appreciate that the Trust has acknowledged the complainant’s fall and moved the scales out of the way following the complainant raising their concerns, we think more could be done to address the impact of this complaint. Therefore, our decision is we partly uphold this aspect of the complaint and we will make recommendations to the Trust.
    
    Fall aftercare
    
    33.	The complainant told us three members of staff helped him up after his fall, but nobody reported the fall. The complainant does not think the Trust should have sent them home straight away and is concerned that no one checked up on them after the fall and the Trust did not promptly inform their GP of their fall. The complainant told us their walk home took 30 minutes longer than it usually does because they felt dizzy and had to keep sitting down.
    
    34.	The Trust acknowledged in its complaint response letter dated 4 July 2018 that a doctor should have been asked to review the complainant before they were sent home and the Trust should have carried out an X-ray to check the complainant had not been seriously harmed. The Trust also acknowledged that it did not document or report the complainant’s fall and it should have done. It also acknowledged that this caused a delay in it informing the complainant’s GP.
    
    35.	Our clinical adviser is in agreement with the Trust’s view that after the fall and before they were sent home the Trust should have arranged a review by a doctor to check the complainant did not have a serious injury. Our clinical adviser told us the decision to carry out an X-ray would have depended on the judgement of the doctor’s assessment.
    
    36.	The Trust’s incident policy  says the Trust should make an electronic report of any incident where someone could have or did experience harm on the Trust’s premises within 24 hours of the incident happening.  While the General Medical Council’s guidelines  say a record of events should be made at the time or as soon as possible afterwards setting out any relevant clinical findings and the agreed action to be taken to address those clinical findings. 
    
    37.	In accordance with the Trust’s incident policy and the General Medical Council’s guidelines we would have expected the Trust to have written an incident report after the complainant’s fall, to have made a note of the incident in the complainant’s clinical records and to have promptly informed the complainant’s GP. The Trust did not do this. Accordingly, our decision is there has been a failing in the Trust not arranging for a doctor to review the complainant after their fall and before they went home. Our decision is also that there was a failing in the Trust’s lack of prompt communication with the complainant’s GP and the lack of record keeping following the fall.
    
    38.	The complainant says they found the lack of care by the Trust very distressing. They also told us when they went to see their GP they had no idea about their fall and it was only at that point the complainant was given painkillers, referred for an X-ray of their shoulder and later referred for physiotherapy due to the pain in their right shoulder. 
    
    39.	We recognise that it will have been distressing for the complainant to believe the Trust did not care for them as it should have done following their fall. If the Trust had provided proper after care to the complainant on the day of their fall they may have had their X-ray earlier and it is likely they would have received pain relief and physiotherapy earlier. Our clinical adviser has highlighted that this may not have reduced the severity or duration of the complainant’s symptoms. So, the ultimate outcome may not have been different even if the complainant had an early assessment of their shoulder. However, we are persuaded that the pain may have been managed better and the complainant has missed the opportunity to ever know whether they would have experienced less pain and therefore less associated mobility difficulties.
    
    40.	While the Trust has acknowledged it could have done more for the complainant after their, apologised in its letter dated 4 July 2018 and has reminded staff of the importance of record keeping we think more could be done to acknowledge how the Trust not giving the complainant medical attention at the time of their fall may have meant that there was a delay in the complainant’s pain being addressed and a missed opportunity for possible further support. Therefore, our decision is we partly uphold this aspect of the complaint and we will make recommendations to the Trust. 
    
    Complaint handling
    
    41.	The complainant complains that the Trust ignored the letters they sent between February and May 2018 and the Trust only responded when the complainant sent another letter via recorded delivery, addressed to the Chief Executive. The complainant told us they do not have copies of the letters or proof the Trust received them.
    
    42.	The Trust said it only received one of the complainant’s letters on 23 May 2018.
    
    43.	While we have no reason to doubt the complainant sent these letters, we do not have any impartial information to conclude that the Trust received them. This means we do not have enough evidence to say there was a failing in the Trust ignoring the letters the complainant sent before the letter the Trust received on 23 May 2018. We do not uphold this part of the complaint.
    
    
  • 44.    We consider that the Trust did not take all reasonable steps to reduce the risk of the complainant falling over the weighing scales on 30 January 2018. The Trust did not arrange for a doctor to review the complainant after their fall and before they went home. We consider that there was a lack of communication with the complainant’s GP and poor record keeping following their fall. We cannot say that the fall caused the damage to the complainant’s right shoulder however we appreciate it is likely to have been painful at the time, it appears to have triggered ongoing pain and the missed the opportunity to access pain relief and physiotherapy earlier along with the possibly to be considered for support at home earlier could have potentially resulted in a better overall outcome for the complainant.
    
    45.	Accordingly, we have made recommendations below to go towards putting right the distress we have identified as a result of the failings we have found.
    
    46.	In considering our recommendations, we have referred to our Principles for Remedy. These say where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. 
    
    47.	Our Principles state that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately. In line with this, we recommend that that by Monday 16 November 2020 the Trust apologises to acknowledge the pain that the fall has caused them and how the Trust not giving the complainant medical attention at the time of his fall may have meant that there was a delay in the complainant’s pain being addressed and a missed opportunity for possible further support.
    
    48.	As well as an apology the complainant would also like reimbursement of the £1300 they paid to a carer for eleven weeks after their fall. The complainant has told us they do not have anything they can share with us to show they paid £1300 on care costs. While we do not doubt the complainant, we make impartial and evidence-based decisions so without evidence in this case we are not persuaded we can formally recommend the Trust reimburse this cost. 
    
    49.	However, we are persuaded a financial remedy would be reasonable to address the pain, distress and inconvenience experienced as a result of the fall.  Therefore, we have reviewed similar cases where similar injustice has arisen, and we have referred to our guidance on financial remedy to decide what we think would be a suitable financial remedy. Following this review, we recommend that by Monday 16 November 2020 the Trust should pay the complainant £500 in recognition of the pain the complainant experienced due to the fall itself and the pain the fall appears to have triggered and the missed the opportunity to access pain relief and physiotherapy earlier along with the possibly to be considered for support at home earlier all of which could have potentially resulted in a better overall outcome for the complainant. 
    
    50.	Our Principles also say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they does not repeat maladministration or poor service. 
    
    51.	The Trust did not created a Datix report for the complainant’s fall, nor has the Trust provided us with any evidence that it created one in retrospect once it had received the complaint about the fall. We recommend that by Monday 11 January 2021 the Trust tells the complainant and ourselves what action it has taken to ensure that Datix reports are created at the time of incidents in the future. 
    
    52.	We also note that policies for the Prevention and Management of Patient Slips, Trips and Falls appear to be common practice in NHS Trusts.  We could not find a policy for Trust policy online so in an email on 17 August 2020 we asked the Trust whether it had its own policy on this matter. In response to our request the Trust sent us a copy of its Prevention of workplace falls – staff and visitors’ policy. We recommend that by Monday 11 January 2021 the Trust provides us with evidence that staff are aware of their responsibilities according to the policy. The Trust should also send an anonymised copy of our final report and evidence of the action that the Trust has taken to comply with this and our recommendation in paragraph 51, above, to the Care Quality Commission and NHS Improvement.