Decision Report 201201571

Summary

Following a severe stroke a number of years ago, Mr C's wife (Mrs C) has had a number of ongoing health issues, including being unable to speak. Her shoulder (on the side affected by her stroke) has been dislocated several times. On one occasion, Mrs C attended the accident and emergency department of a hospital because her shoulder was painful. An x-ray was taken and an emergency doctor attempted to manipulate her shoulder back into position while she was sedated, fracturing one of the shoulder bones in the process. This was treated conservatively (with medical treatment that avoids radical therapeutic measures or operations) but Mrs C required hospital admission and her arm was immobilised.

Mr C complained that as a result of the fracture and bruising, Mrs C suffered a lot of pain. She also had to wear a sling and shoulder brace which made her life more difficult. Mr C said that the manipulation carried out was unreasonable and that Mrs C should not have had to cope with its consequences, particularly given the aftermath of the stroke.

During our investigation we took independent advice from one of our medical advisers, who examined Mrs C's medical records. Their advice, which we accepted, was that it was not reasonable to carry out the manipulation, because the shoulder was effectively not dislocated and there was a very high risk of a fracture occurring. These were significant failures. Furthermore, we were not satisfied from the medical records that Mrs C was fully informed of the risks of the procedure, or that the doctor properly obtained consent.

Recommendations

We recommended that the board:

• put in place a clear protocol for the treatment of chronic dislocation and subluxation (partial dislocation of a bone in a joint) of the shoulder particularly for patients with neurological abnormalities;
• ensure that written consent is obtained for invasive procedures, including the complications, which should be obtained prior to such procedures being undertaken and clearly recorded in the notes;
• ensure these issues are raised with the emergency department doctor as part of his annual appraisal; and
• apologise to Mr C for the failures identified in this investigation.