• Case ref:
  • Date:
    January 2018
  • Body:
    Forth Valley NHS Board
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Upheld, no recommendations


Mrs C complained about the care and treatment her husband (Mr A) received at Forth Valley Royal Hospital. Mr A was admitted to hospital after sustaining a fracture to his thigh bone. An operation was carried out to insert a pin into the thigh bone to secure the fracture. During the operation, the wrong size of screw was used to fix the pin to the bone. Medical staff discussed this situation with Mr A following the operation, and it was agreed that a further operation would be carried out to replace the screws with those of a correct size. This operation was completed successfully and, after a period of recovery, Mr A was discharged home. Mr A was then re-admitted to hospital after he became unwell. The board carried out blood tests which showed signs of infection, yet it was not clear where the source of the infection was. Mr A's condition deteriorated and he died from a bowel condition related to the infection.

Mrs C complained that the wrong screw was used in the first operation and she felt that the second operation had caused the infection that led to Mr C's death. The board apologised to Mrs C about the use of the wrong screw and informed us that this issue had been discussed at a number of clinical meetings in order to prevent the issue from happening again.

We took independent advice from a consultant orthopaedic and trauma surgeon. They considered that the care and treatment provided to Mr A was reasonable, with the exception of the use of the incorrect screws. The adviser said that, in their opinion, the infection related to Mr A's re-admission was not linked to the orthopaedic treatment he received. Although we were unable to conclude that the orthopaedic treatment received led to Mr A's death, we upheld this complaint and asked that the board send us evidence of the steps they said they had already taken to prevent this from happening again.