After the Fall: The Investigation

Last October I wrote two posts - here and here - about a horrible fall which saw me break my elbow and end up in Ealing Hospital. There, a failure to recognise that I had suffered an open fracture - one where the bone pierces the skin - led to me receiving inadequate care which put me at risk of suffering a dangerous infection. Even when that mistake was rectified I faced unacceptable delays in getting the antibiotics and then the surgery needed.

Ealing Hospital, around midnight 13th October 2023

I have now received the results of the Patient Safety Investigation, a major piece of work where a group of senior doctors spent five months examining my case for the London North West University Healthcare Trust and trying to learn lessons from it. Given that one social media user attacked me for having “the front to complain to the Trust” I must stress that I never made a formal complaint - it was the Trust which decided after an initial review that a full investigation was merited.

I won’t publish the full report and I want to be clear that I have no criticism of the hard-pressed staff who did their best under extremely trying circumstances. But the conclusions of the investigation reveal what I suspected all along - that poor communication combined with inadequate technology were to blame for what went wrong.

First, a simple timeline:

Friday 13th October.

At 7pm I arrive at Ealing Hospital with cuts to my face, a missing tooth, and severe pain in my right elbow. When I remove my coat blood pours from my right sleeve. Doctors examine me and send me for a CT scan of my head and an x-ray of my elbow, which reveal that there is no brain bleed but I have a badly broken elbow. At first I am told I will stay overnight and have surgery in the morning. Then after a plaster cast has been applied and another x-ray has been taken, I am sent home at 4am and told to expect a call about surgery early next week.

Tuesday 17th October.

At noon I get a call from the hospital asking me to come in for a CT scan of my elbow, which will help in the preparation for the surgery. This is done swiftly and efficiently and I return home, only to get a call at 5pm telling me to return to the hospital urgently. The scan has revealed that there is air in the wound, indicating I have an open fracture. They want to get me on an antibiotics drip and prepare me for surgery. I suddenly realise that my right arm has become swollen.

I arrive back in the emergency department at 7pm to find it very busy. There are a number of new tests and I finally get a bed on a ward at 1 am. By now I have been told to fast in preparation for an operation in the morning but, despite my repeated requests, it is not until 3 am that I am put on the antibiotics drip.

Wednesday 18th October

At 10.15 am I am told that the operation will not be happening today because I’ve not been on the antibiotics for long enough. I am put on the list for Thursday and told to fast from midnight.

Thursday 19th October

At 11 am I am told that the surgery has been cancelled again, this time because an emergency patient bumped me off the list. By now I am thoroughly fed up and after long discussions it is decided that I should have the operation done at Northwick Park Hospital, where there is a surgeon who specialises in arms.

Saturday 21st October

After one more piece of miscommunication where administrators at Northwick Park try to contact me on a landline which no longer exists, the operation on my elbow finally takes place.

The investigation report sets these events out in great detail and is very frank about the failings of the system. I was given the opportunity to send in some questions and when I asked whether I would have been sent home on that Friday night if someone had spotted that I had an open fracture, the answer was clear:

“The National guidelines for low energy open fractures is admission for antibiotics and surgery within 24 hours. If the open fracture was known, then you would not have been discharged home and you would have required admission.”

Given the amount of blood that poured out of my right sleeve when I took my coat off, it surprises me that the injury to my elbow was described as a “small graze.” But understandably the focus was on my head injury and once one doctor had failed to notice the open fracture, it seems the others saw no reason to think differently, especially after a plaster cast made the wound invisible.

But the really startling new piece of information was that the very first x-ray of my elbow showed air (sometimes called gas) in the soft tissue, indicating this could be an open fracture. Extraordinarily, nobody noticed this either on the Friday night, nor on Monday and Tuesday mornings at the daily trauma meetings where the orthopaedic team reviewed my case.

The report puts some of the blame on technology:

“The computer screen where the trauma meeting is held was not entirely compatible with PACS (Electronic system where x-rays are stored for viewing) resulting in poor resolution of the x-rays.

Images sent remotely were viewed on a mobile device, also lacking enhanced quality.”

It seems crazy that at a meeting where doctors are making decisions about treatment a key resource in assessing a patient was defective, rather as if a pilot landing an aircraft was forced to wear a blindfold. Equally if on-call doctors are viewing x-rays at home, surely they should be looking at a bigger screen than that of a smartphone?

Having finally got to grips with the need to get me on antibiotics and then into surgery, Ealing Hospital then took seven hours to put me on a drip. This time, the fault was again poor communication but there was some excuse - it was a hugely busy night in the emergency department and at a key moment a junior doctor who had been asked to prescribe the antibiotics was called away to attend an emergency.

Then there was another issue with technology. Unbelievably the hospital records system which includes each patient’s drug chart had only just gone electronic in August and was still “bedding in”. Up until its arrival, the drug chart was a paper document and for some unfathomable reason, this had been more flexible and would have allowed my antibiotics and other drugs to be supplied the moment I arrived on the ward.

As for the repeated delays in my operation, that was down to resources - a lack of theatre space and the fact that the one specialist upper limb surgeon only worked on Mondays. It appears that on other days, cases that weren’t too complex could still be undertaken by lower limb surgeons but mine turned out to be quite a difficult fracture. It sounds as though I should have been referred to Northwick Park straight away but the report suggests there was a lot of dilly-dallying:

“There was a lack of decision-making regarding whether this surgery would be optimally conducted by a UL [upper limb] surgeon, leading to a delay in the referral to NPH [Northwick Park Hospital].”

In its conclusions the report says “the failure to identify the open nature of the fracture led to a cascade of missed opportunities for timely treatment.” And it says the problem was compounded by poor communication, both within the hospital and between hospital and patient:

“Inadequate communication channels and processes led to critical information about the patient's condition not being effectively communicated between healthcare professionals, resulting in missed opportunities for timely diagnosis and treatment.”

The report comes up with 11 recommendations to improve matters, including an improved screen in the room where the trauma team meets, more training for staff in spotting open fractures and an audit of the night shift in the emergency department to work out whether the nights involved were exceptionally busy or there is a need for more staff.

While on the face of it I suffered no lasting damage from my week waiting for treatment, it has had an impact. Six months on from the accident, I am still having physiotherapy and my arm is not yet totally straight. Perhaps it never will be - I joke that my dream of opening the bowling for the England cricket team is over because I would be labelled a “chucker’. And it may be a coincidence but my Parkinson’s has progressed - and not in a good way - so that I am now finding walking a lot more challenging than it was before I fell over.

When I first wrote about the story of my broken elbow, I received dozens of messages from people who had had far worse experiences with the health service than mine. It has become a cliche to say we love the NHS but having received excellent treatment for an ocular melanoma and for Parkinson’s I am a huge fan.

But that does not mean we should ignore its faults or assume that they are all thert of insufficient government funding. There are plenty of things wrong with the way healthcare is managed, with a culture that is still too hierarchical, with technology that costs a fortune but doesn’t work.

These problems need facing, not hiding away from. Which is why I would like to end by thanking the team that produced this very comprehensive and frank report. If we are to make the NHS better we first have to be honest about its faults.