Patient Complaints

The case history is based on actual medical negligence claims or medico-legal referrals; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved.

Complaints against medical practitioners are not uncommon. The Health Care Complaints Commission receives a formal written complaint each year for 1 in every 20 NSW doctors.

Neck and neck, a lucky escape

A 15 year old school boy was injured during a Saturday rugby match. He felt something "give" in his neck and experienced pins and needles in his arms and legs over a period of several minutes. The school boy was transferred to the local emergency department (ED) by ambulance. The ED Intern quickly examined the patient and organised cervical spine x-rays. The Orthopaedic Registrar was then asked to review the patient. Physical examination was normal and no abnormality was noted on the cervical spine x-rays by either of the doctors. The patient was subsequently discharged home with a soft cervical collar in place.

Some days later the patient saw his GP who ordered further cervical spine x-rays. These x-rays revealed a fracture of C6. The patient was admitted to hospital and following appropriate treatment, made a full recovery.

The patient's mother wrote a letter to the ED complaining about the management provided to her son by the Intern and Orthopaedic Registrar. Review of the cervical spine x-rays taken at the hospital revealed that they were of very poor quality and the C6 and C7 vertebrae were not adequately visualised on the films.

Additionally, reporting of the cervical spine x-rays by the Radiologist on the following Monday morning indicated a possible abnormality of C6. The Radiologist recommended that further x-rays should be performed. However, this information was not followed up.

As a result of this incident, a protocol was put in place in the Radiology Department to ensure the quality of radiographs taken on the weekend were of an adequate standard. Additionally, a system was put in place for the follow up of abnormal test results in the ED.

The Intern and Registrar sought advice from their MDO regarding an appropriate response to the complaint. The patient and his mother were provided with a full explanation, including a discussion of the steps that had been taken by the hospital to prevent another similar incident. In the letter of response, the Intern and Registrar also apologised to the family as they were aggrieved regarding their management. This response was accepted and the matter was concluded to the satisfaction of everyone involved.