Decision Report 202310053

Summary

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation.

C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months.

The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist.

We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint.

In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• The Morbidity and Mortality meeting scheduled should include input from physiotherapy; discuss appropriate escalation procedures, including who to contact if a consultant is unavailable; and how patients are reviewed as inpatients, with a view to reviewing patients daily.