Why on earth are so many broken bones not spotted in casualty?

As the NHS is forced to pay out millions in compensation for missed hand fractures alone . . .

You fall over and the pain is so bad you think you may have broken something, so you take yourself off to A& E. That’s what hundreds of thousands of us do every year — yet too often doctors aren’t spotting broken bones.

When Sam Brooks was 15 he fell over during a football match after colliding with another player. He felt a sharp pain in his left wrist and assumed it was broken.

His father Mike drove him to nearby Addenbrooke’s Hospital, in Cambridge, where he was given an X-ray.

Doctors told him they suspected he had a hairline fracture (a crack rather than a complete break) in the scaphoid bone, just below the thumb, where the wrist joins the hand. His wrist was put in a plaster cast and he was told to come back in just over two weeks.

But when he returned, a junior doctor looked again at the X-ray, saw Sam could move his wrist and concluded he didn’t have a fracture at all. Sam was told to go home.

But over the next two years he suffered increasing pain.

‘It was agony,’ says Sam, 19, a trainee building services engineer from Huntingdon in Cambridgeshire. ‘I was waking up in the night in pain and even the simplest tasks, like holding a cup of tea, became extremely difficult.’

Finally, Sam went to his GP, who sent him to Peterborough City Hospital for more X-rays.

These revealed that the junior doctor had read the original X-ray wrong. Sam had indeed suffered a fracture and, because the plaster had been removed and no further treatment had been given, it had not healed properly. Rather than needing a plaster cast, Sam now required surgery that involved taking bone from another part of the wrist to ‘fuse’ the cracked scaphoid bone.

WITHouT

the operation, Sam was told, he risked developing arthritis in his wrist by the age of 30.

‘The doctor told me the bone around the fracture had died because it hadn’t been treated properly, and I would need a pin inserted to stabilise it and a bone graft to help it heal,’ says Sam.

A recent report showed the NHS is paying out millions of pounds a year in compensation for broken bones not spotted in A&E.

Most claims involve injuries to the hand and wrist, which contain such small bones that fractures and breaks may be hard to spot. untreated, they can lead to a lifetime of complications and pain.

Missed breaks, or inadequate treatment for breaks, in the hand alone cost the NHS more than £6 million in the past decade. The sums paid to the 200 people affected range from £10,000 to £1 million. These figures came to light in a Freedom of Information request to the NHS Litigation Authority by doctors from two London hospitals, St George’s and the Royal Free, and were reported in the Medico-Legal Journal.

Yet it’s not just hand injuries that doctors are missing.

An investigation by St Mary’s Hospital, in London, found more than £5 million was paid out by the NHS over the past decade for undetected broken hips.

NHS Litigation Authority data reveals that 148 patients successfully claimed for this in the ten years to 2015. Almost half the claims were due to a delay in diagnosis — and there was no sign mistakes were declining, despite tougher guidelines in recent years.

Any undiagnosed break or fracture increases the risk of a socalled non-union, where a broken bone does not fuse correctly.

Even with proper treatment, non-union can be a problem, occurring in 9 per cent of scaphoid fractures if they are detected and treated within a few days by putting the wrist in a plaster cast, according to the Royal College of Emergency Medicine.

But if treatment is delayed beyond four weeks, the non-union rate soars to 45 per cent — often resulting, as in Sam’s case, in major treatment to correct it.

Patients’ groups have expressed alarm at the scale of the problem.

‘Healthcare professionals are under huge pressure, but they must give due care and attention to identifying such injuries,’ says Katherine Murphy, chief executive of the Patients Association.

So why are these fractures being missed in the first place?

In the report in the MedicoLegal Journal, researchers suggested errors by junior doctors and nurses were mostly to blame.

Back in 2002, a study in the BMJ showed junior doctors in A&E missed up to 39 per cent of ‘clinically significant abnormalities’ on X-rays because they were too inexperienced to interpret the images accurately.

Concerns over this led to many NHS hospitals implementing a rule that all X-rays should be reviewed by a specialist — either a radiologist (a fully qualified doctor who specialises in analysing images from X-rays, CT or MRI scans) or a specially trained radiographer, a technician who usually takes the images.

But the latest figures suggest this measure has not helped.

ASHIS

BANERJEE, a retired specialist in emergency medicine who led the study in the Medico-Legal Journal, says one problem is that there are often delays of several days in radiologists or radiographers reporting back on an X-ray image — by which time bones may already have ‘knitted’ incorrectly.

‘Some fractures are subtle,’ he says, ‘ so all X-rays taken in the majority of emergency departments in the uK are reported on by radiologists.

‘But delays in reporting by them may lead to delayed treatment.’

Another factor, he adds, could be the drive to divert minor injury cases away from clogged A&E departments to urgent care centres, which are rarely staffed by doctors.

The Society of Radiographers says missed fractures are partly due to a shortage of radiologists to provide a round- the- clock service in casualty departments.

official figures show the uK has just seven radiologists for every 100,000 of the population. Yet NHS trusts are failing to utilise the uK’s 30,000- strong workforce of radiographers to fill the gaps, the society says.

‘Radiographers are perfectly capable of reporting back (to doctors and nurses) on bone images, providing they have had the right training,’ a spokesman told Good Health. ‘But in some hospitals there is a real resistance to providing the training.’

The Royal College of Radiologists says the number of qualified radiologists in the uK has risen by only 5 per cent in recent years.

But the demand for X-rays, MRI and CT scans has soared by nearly 30 per cent in the same period. Last year, the National Institute for Health and Care Excellence (NICE) urged doctors to consider ordering an MRI scan as well as an X- ray in cases of suspected scaphoid fracture, as it gives a more detailed image.

But the college claims 99 per cent of radiology departments can’t keep pace with the demand for scans, not just for fractures but for life-threatening illnesses.

A broken wrist may not seem that serious, but Sam’s case illustrates how failing to spot one can have life-changing implications. He had to abandon plans to join the Armed Forces or become a PE teacher or footballer because, even after the bone graft, his wrist still can’t bear much weight.

Lawyers at Irwin Mitchell helped him win an undisclosed sum in compensation, but he says the money can’t make up for the impact on his life. ‘It ruined my dream of becoming a professional footballer,’ he says. ‘Things were going really well and at 15 I was already playing semi-professionally for Godmanchester Rovers.

‘The fear of falling and injuring my wrist further wrecked my confidence on the pitch.’