The Penningtons Manches clinical negligence team has recently agreed the settlement of a claim against Northwick Park Hospital for the alleged failure to appropriately diagnose and treat a client’s shoulder dislocation during his A&E attendance, causing a delay in treatment and avoidable nerve damage.

The client injured his shoulder after falling off his bicycle. He was in a great deal of pain and was unable to move the affected shoulder and arm. He also considered that there was a very obvious deformity of his shoulder which he described as appearing “lop-sided”.

He attended his local A&E department very soon after his accident where he was initially assessed by a triage nurse and then an A&E clinician. Following a physical examination of the injury, the A&E clinician ordered an X-ray to assess the extent of the injury further. Upon receipt of the X-ray results, the A&E clinician reviewed him again and considered that the X-ray had specifically ruled out any dislocation. He sent him home with a diagnosis of a soft tissue injury. Unfortunately, overnight, his severe pain persisted and he experienced an onset of numbness in the fingers of his right hand, coupled with an inability to move and flex his fingers.

As is standard in most A&E departments, the client’s X-rays were reviewed by a different radiologist the day after his discharge. This procedure is adopted as part of “safety netting”, which involves screening certain forms of tests performed within an A&E department with the aim of detecting any missed fractures, dislocations or misdiagnoses made by medical practitioners during a patient’s initial attendance. This review revealed a shoulder dislocation and it was recognised that his injury had been wrongly diagnosed.

He was then recalled to A&E urgently for the dislocation to be appropriately treated. Unfortunately, by the time of his return to A&E, some 24 hours after his original attendance, the client was noted to have suffered injury to his nerves (neuropraxia), which had not been present during his original attendance.

During the course of Penningtons Manches’ investigations, expert evidence was obtained to assess the standard of care given to the client during his original A&E attendance and, if any failings were identified in the management of his injury, whether any such failings were detrimental to his outcome. A supportive independent expert opinion ascertained that the original X-rays performed at A&E demonstrated an “obvious dislocation of the glenohumeral joint” and that any reasonably competent A&E clinician should have detected the dislocation and treated it without delay. The expert was of the opinion that, as a result of the 24 hour delay in treating the shoulder dislocation, the client developed neuropraxia which was caused by the prolonged stretching of the part of the brachial plexus that supplies the C7 and C8 (ulnar side of the hand), affecting sensation and movement.

A letter of claim in accordance with the Pre-Action Protocol for the Resolution of Clinical Disputes was therefore submitted to the London North West London NHS Trust. A full admission of liability was received and a good settlement was reached at an early stage, without the need for litigation.

Naomi Holland, a member of the clinical negligence team who ran this case, said: “This case highlights the implications that a delay in treating a dislocation can have on a patient and therefore, stresses the importance that any test or investigation results are carefully assessed, so that the correct diagnosis can be achieved. Thankfully, in this case, our client’s X-rays were reviewed by a different doctor following his discharge, albeit his injury had already deteriorated by this time. Our client wanted to pursue a case to highlight the issues in his care in the hope that future incidents similar to his experience can be avoided”.