Failure to diagnose and operate on fractured femur caused pain

What happened

Mr M attended A&E with pain in his left femur (the bone of the thigh). The Trust conducted X-rays but didn't find any fracture. It then discharged Mr M to the short stay medical unit where he was encouraged to weight bear (try to let his leg support him). After a few days Mr M's leg broke while he was walking. He had an operation to fix his leg and was admitted to the high dependency unit. However, four days later Mr M died. The nursing staff did not call his family, so they were not there when he died.

The Trust then incorrectly listed cause of death as pneumonia but his family disputed this. Following a meeting with the medical director, the Trust changed cause of death to 'pathological [extreme] fracture left femur (operated)'.

The Trust also incorrectly filled in the cremation form that it gave the funeral directors. It had stated that dangerous nails were left in Mr M's body. When the funeral directors asked the Trust to remove the nails it refused. The funeral directors then had to arrange with another hospital for the nails to be removed and the family was charged a fee for this. In fact the nails did not have to be removed.

What we found

We partly upheld this complaint. We found a number of failings by the Trust. It failed to conduct an appropriate scan in A&E and to conduct the appropriate discharge process to the short stay medical unit, which led to Mr M being incorrectly advised to keep mobile. There was also a delay in performing the operation on Mr M's leg and the Trust gave incorrect information to the funeral directors.

We could not conclude that the failings led to Mr M's death. Surgery on his leg would have been required in any event and we could not predict whether he would have recovered from this surgery. However, we concluded that Mr M suffered unnecessary pain and discomfort, and that it was likely his chances of survival would have been increased by earlier intervention and a more appropriate assessment. The events that occurred after Mr M died caused his family unnecessary stress and upset.

Putting it right

The Trust apologised and paid Mr M's family £1,500. It also produced an action plan outlining areas of improvement and lessons learned as a result of our investigation.