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Dislocated care

01 November 2004

Ms R, a 24-year-old veterinary nurse, crashed her car. A fire crew had to cut her from the wreckage. She sustained a chip fracture of the fibula and a radial fracture, diagnosed in hospital. Facial x-rays were noted as showing no bony injury other than nasal fracture.

Ms R was admitted under the care of the orthopaedic team who referred her to the ENT department.

This was due to her nasal bone fractures and persistent pain on the right side of the mandible when chewing. She was seen twice by a registrar, Dr T, who advised that she be referred for a dental opinion. This referral was not made. Ms R received standard treatment for her other injuries and was eventually discharged from hospital and followed up in orthopaedic outpatients.

Ms R continued to have jaw pain and went to see an oral surgeon about two months after her accident. It transpired that she had suffered a fracture-dislocation of the right mandibular condyle. She needed prolonged orthodontic treatment with teeth and head braces. It was too late to perform an inter-dental wiring technique.

She issued a claim against the hospitals responsible for her treatment and her orthopaedic consultant. It alleged failure to properly carry out an examination, a failure to x-ray the jaw, a failure to correctly interpret x-rays that were taken and failure to diagnose the mandibular fracture dislocation.

It was claimed that this resulted in her suffering from facial asymmetry and having to undergo prolonged and painful treatment which could have been avoided.

Expert opinion

We sought expert orthopaedic opinion. This identified the main deficiency as a clinical and radiological failure to diagnose the mandibular fracture. With the benefit of hindsight the expert was able to detect the mandibular abnormality on the two facial x-rays, but conceded that the views taken were unsuited to diagnosis of the fracture. The orthopaedic treatment was not criticised and it was held that appropriate referrals had been made.

ENT opinion held that Dr T’s assessment was adequate as he was given no history of jaw pain, but did note mandibular tenderness and an uneven bite.

The expert thought it could be argued that Dr T should have ordered appropriate x-rays, but felt that his status as an ENT trainee and not an expert on maxillofacial fractures, plus the fact that he’d advised a dental opinion, meant he was not at fault.

The ENT expert felt that the responsibility for making the referral lay with the orthopaedic team, as the clinicians in charge of her inpatient care.

The matter was due to go to trial, with the insurers of the at-fault driver insisting that the responsibility for the settlement was not theirs, due to clinical negligence of the doctors caring for Ms R.

After negotiation, we agreed to contribute £10,000 towards Ms R’s costs. The car insurers eventually agreed to pay £100,000 compensation, which Ms R received in an out-of-court settlement. 

Comment

  • Seeing referrals from other specialties – When a colleague asks for a specialist opinion, that is what they are entitled to. It is important for specialists-in-training to gain experience by seeing referrals from other departments, but it is a good idea to ensure that they have enough experience to do so, and receive an appropriate level of support/supervision if they are conducting an initial assessment alone.
  • Giving and taking advice – If you ask for specialist advice, you must consider it carefully, particularly if you are advised to seek the opinion of another specialty. Failure to do so will leave little room to defend your actions if there is a subsequent problem. When giving advice it is important to be clear and precise, particularly about the steps that have been taken and need to be taken.
  • Co-ordinating care – The most important person in a clinical setting is the patient. Take care that professional pride or confusion over roles does not interfere with the delivery of appropriate care. In this case our experts disagreed about whose responsibility it was to arrange the appropriate opinion, but it is clear that there was a failure of clinical team-working.
  • Assessing trauma cases – After trauma, once a patient is stabilised, it is important to fully examine the patient and assess the need to x-ray parts of the body that are not obviously involved in the primary injury. This is particularly important if there are relevant symptoms indicating damage or dysfunction. Trauma teams and radiology departments should liaise on protocols for appropriate x-ray screening of injury, and for review of films by suitably experienced members of either team, to ensure that difficult-to-spot abnormalities are not missed.
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