Trust may have missed opportunity to prevent DVT for patient with lower limb plaster

What happened

When Mr S went to A&E with severe pain and swelling in his leg, the Trust diagnosed tenosynovitis, which is inflammation of the tissue around a tendon. Trust staff put a plaster of Paris on his leg. The plaster was not weight–bearing.

A few weeks later, Mr S was diagnosed with cellulitis, an infection of the soft tissue or skin, and a DVT in his leg and his lung. Mr S asked why the Trust diagnosed tenosynovitis, why staff did not consider cellulitis, why staff did not think about DVT, and whether the plaster of Paris caused or worsened the DVT. He also wondered whether, if the Trust had found the DVT earlier, things could have been different.

The Trust explained the care and treatment it gave Mr S. It said several doctors saw him in A&E and they were all convinced that he had tenosynovitis. The Trust said that at that stage, there were no clear features of DVT. It added that the duration of his symptoms and that they improved in plaster supported the diagnosis of tenosynovitis, for which a plaster cast is a well established treatment. It added that a DVT is a recognised complication of being immobilised in plaster. The Trust said that there was no evidence in the records that staff missed a DVT.

There was a local resolution meeting at which Mr S's concerns were discussed and the Trust gave a final response. The Trust maintained its position that the DVT was not missed but rather was a complication of the plaster of Paris.

What we found

The diagnosis of tenosynovitis and the decision to treat it with a plaster cast was appropriate. However, there were failings because the Trust did not assess Mr S for measures to prevent thrombosis in line with the relevant guidance and did not give him a weight–bearing plaster.

We were unable to conclude that if Mr S had been assessed for measures to prevent thrombosis, he would have met the criteria for treatment or to what extent the provision of a walking plaster or boot would have reduced the risk of DVT. However, we consider that the failings we identified meant that the Trust may have missed an opportunity to reduce Mr S's risk of getting a DVT. This is upsetting for Mr S because he will never know whether an earlier intervention could have made a difference to his condition.

Putting it right

The Trust apologised to Mr S for the impact its failings had on him and paid him £250 to reflect the injustice he experienced.

It agreed to develop an action plan that describes what it will do to implement the guidance on measures to prevent thrombosis in patients treated with lower limb immobilisation, and will set up a system to redirect, when appropriate, patients who need specialist but non emergency treatment.