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Unseen x-ray indicated fracture

01 May 2006

A 67-year-old housewife, Ms T, was admitted to an A&E department having collapsed at home and been unconscious for five minutes. Ms T had fainted eight weeks previously and been admitted to a different hospital. She had also fainted six weeks previously. There was no evidence Ms T had experienced a fit.

Ms T was admitted under the care of the on-call physician but was subsequently transferred to Dr G, a consultant physician, who had seen her previously. Ms T had injured her face but was otherwise well. There were no abnormal neurological findings and routine blood tests, an ECG and CT scan of the head were both normal.

During a subsequent ward round Dr G requested an x-ray of Ms T’s jaw. He was given a verbal report of the x-ray film by Dr O, a registrar in radiology, who allegedly stated that the x-ray showed ‘no mandibular abnormality and no maxillary fracture detected either’.

Ms T remained asymptomatic and was discharged home. When Dr G reviewed her in outpatients, she complained of nasal obstruction and numbness in her left lip. She was referred to an ENT surgeon, Dr G, who carried out a septoplasty several months later.

When Ms T’s records were reviewed it emerged that an x-ray of her facial bones had previously been performed in A&E but the report had been filed without being seen by a doctor. This x-ray demonstrated a probable fracture of the floor of the left orbit and, possibly, the nasal bone.

Ms T had sustained a fracture of the left orbit when she fainted but this had not been recognised while she was in hospital. Damage to the infra-orbital nerve that can occur with orbital fractures could have accounted for some of her symptoms.

Dr G maintained that he had not been told that Ms T had undergone facial x-rays on admission and had not been made aware of the results. Ms T had not complained of facial symptoms while she was under his care and he therefore had no reason to suspect a facial fracture. 

Expert opinion

Several experts consulted on behalf of the defendant concluded that it was unclear how much of Ms T’s symptoms could be attributed to the injury. There was also doubt as to whether early treatment would have improved the long-term outcome.

There was no mention of facial x-rays being requested in the A&E notes and, in the absence of symptoms, Dr G could not be expected to diagnose an orbital fracture. It was felt that organisational issues within the hospital were also partly responsible.

It subsequently emerged that x-rays of Ms T’s facial bones had been taken at the time her jaw was x-rayed – whilst she was under the care of Dr G. These x-rays were not reported but clearly showed an orbital fracture. A hand-written letter from a radiologist to Dr G came to light describing a ‘definite fracture of the orbit’. This note was undated and, although it may have been written after Ms T had been discharged, it would have been difficult to prove that it had not been written while she was an inpatient.

The case was therefore settled out of court in favour of the claimant for the equivalent of £50,800, shared between the hospital and two medical protection organisations on behalf of Dr G and Dr O.

Learning points

  • A doctor who requests a test or x-ray has a responsibility to check the result themselves. A&E and acute admission units should develop a protocol to keep track of relevant results.
  • Following an acute admission, patients may be seen by several doctors and transferred between specialties. Detailed notes should therefore be kept. Test results can be made available online, making it easier to check before a patient is discharged.
  • Increasing pressures on radiology departments may result in some x-rays not being reported by radiologists. Clinicians and radiologists should agree a policy to manage unreported films.
  • If x-ray films are not seen by a radiologist, someone with sufficient experience should see the films and write a report in the clinical notes.
  • A radiologist who gives a verbal opinion on an unreported x-ray film should subsequently issue a formal written report.

Further information

For information on treating orbital fractures see www.bmj.com See also Holmes, SB et al (2000) Lesson of the week. Blunt Orbital Trauma, BMJ 321:750-51 (2000) at www.bmj.com.

A review of the diagnosis and management of orbital fractures is available at www.emedicine.com.

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