Delay in diagnosis of shoulder injury and surgery

Posted by Annabelle Eyre on

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Ms B worked as a care assistant in a care home. In October 2010, whilst she was lifting a patient, she heard a crack in her shoulder. She attended her GP surgery and was referred for an x-ray.

The x-ray report showed degeneration and moderate arthrosis of the AC joint but suggested that an undisplaced fracture could not be excluded. The orthopaedic surgeon recommended conservative management but advised that she should be referred for an out-patient clinic for review.

Almost a month later, Ms B attended the fracture clinic at Medway Maritime Hospital (MMH). However, due to an error she had not been booked into the clinic, she was sent to be triaged in A&E. A repeat x-ray was taken showing 'no bony injury' and she was referred to the fracture clinic there.

Shortly afterwards, she was seen in the fracture clinic at MMH by consultant orthopaedic surgeon. The surgeon was unable to rule out a traumatic rotator cuff tear and requested an MRI scan. Over a month later, Ms B underwent an MRI scan of her shoulder which reported a 'complete tear of the supraspinatus with retraction. Partial tears of the infraspinatus.'

The MRI findings however were not conveyed to Ms B's GP until April 2011. Shortly thereafter she was seen again by the fracture clinic and was advised to ask her GP to refer her to an upper limb specialist.

Towards the end of July 2011, she was seen in the orthopaedic clinic when it was noted that "since [December 2010] this poor lady has had no further access to treatment and she is obviously upset about the near 7 month delay before she has had this appointment to come and see me…'" He noted on examination a severe weakness in the shoulder and an inability to lift the arm more than 60 degrees in forward elevation. On review of the MRI "early superior subluxation of the humeral head is shown which may have in fact deteriorated over the last 7 month…".

She was added to the waiting list for right shoulder arthroscopy and rotator cuff repair. She eventually underwent surgery on 16 March 2012 some 15 months following the MRI scan which revealed her acute injury. The tear was described as complex with "infraspinatus partially torn and retracted in excess of 5 cm."

BL Claims solicitors were instructed by Ms B investigate. The evidence was clear that the repair to the rotator cuff should have been undertaken much earlier, and, following receipt of the letter of claim, the Defendant admitted that the procedure should have taken place between March and May 2011. However, their offer of settlement failed to take into account the considerable loss of earnings and pain that Ms B had endured.

Eventually after some negotiation, settlement was eventually reached in the sum of £42,000, of which our client received £23,732 after the repayment of the benefits to the DWP.

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About the Author

Annabelle is a solicitor in our Clinical Negligence team.

Annabelle Eyre
Email Annabelle
023 8085 7499

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