NHS rapped after failing to diagnose dislocated jaw

NHS Fife has been ordered to apologise after medics failed to diagnose a dislocated jaw sustained when a patient with Alzheimer’s suffered a seizure.

The Scottish Public Services Ombudsman (SPSO) looked into the case after the complainant, known only as “C”, raised concerns about the care and treatment provided by the board to their partner, described as “A”.

Patient A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened previously.

They underwent x-rays and A was referred to oral and maxillofacial surgery (OMFS) who concluded that no further treatment was required. C continued to report their concern about A’s jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment.

This was later re-directed on vetting to OMFS, however, no follow-up review took place by the time of A’s discharge some weeks later.

On discharge, C contacted A’s GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A’s dementia and reduced mobility, they were unable to fully co-operate during their assessment and would not have been able to manage further x-ray procedures.

They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

The SPSO took independent advice from an oral and maxillofacial surgeon and found that A’s initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable.

However, it found that the assessment of A’s jaw by OMFS failed to elicit the clinical

features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

The decision report added: “On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A’s discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C’s complaints.

“We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm.”

The NHS was told to apologise to C for failing to reasonably assess and diagnose A’s dislocated jaw, for the referral to ENT being inappropriately accepted and for the unreasonable delay by ENT in reviewing A which did not take place during their admission.

The SPSO also said the findings of the investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision-making regarding assessment processes.

Responding to the report, NHS Fife’s director of nursing Janette Keenan said: “We recognise that the care in this case fell well below the high standard that our patients should expect and deserve.

“We are in the process of writing to the patient to apologise formally for the failings in the care received. NHS Fife will also be enacting the recommendations of the ombudsman in full.”