NHS Fife has been forced to apologise to a man who ended up paralysed after a neck collar was removed during his treatment.
The horrifying case was taken to the Scottish ombudsman by the wife of the patient, known only as Mr C. It is not known if Mr C has since regained the use of his legs.
Mr C was admitted to the accident and emergency department of an NHS Fife-run hospital after falling down a flight of stairs.
When he arrived, staff immobilised his neck in a collar and it was recorded that he had movement in both his arms and his legs.
He also had sensation in all his limbs at this time.
But, it was noted there was an issue with Mr C co-operating during his examination by staff.
When a scan showed no acute fracture or any bleeding, his neck collar was taken off.
But his condition took a turn for the worse the following day.
That morning Mr C was found to have lost the use of his legs. He was rushed to another hospital for immediate treatment.
His distraught wife complained that, given the nature of his accident, her husband should have been kept immobile and given a full spinal scan.
She also told the ombudsman, Jim Martin, that she believed proper tests were not carried out to determine the extent of her husband’s injuries and that he should have been transferred immediately to another specialist unit.
Launching an investigation into the case, Mr Martin carefully considered all the information, including Mr C’s medical records, and obtained independent medical advice from a consultant in emergency medicine.
That investigation found that although Mr C had been immobilised as soon as he arrived in A&E his neck collar had been removed, despite recorded difficulties in completing an assessment of his injuries.
Relevant advanced trauma life support guidelines suggested he should have remained in a collar until he was determined to be “normal” neurologically and could have been properly assessed.
Mr Martin upheld the complaint Mr C should have been kept immobile but did not uphold the others as his inquiry found that all appropriate tests were carried out to try to establish the extent of his injuries and that the proper protocol was followed in transferring him to another hospital, rather than to a specialist unit.
He recommended that NHS Fife apologised to Mr C for removing the collar before he was confirmed to be neurologically normal and take appropriate steps to satisfy themselves that advanced trauma life support guidelines are fully complied with.
NHS Fife director of nursing Dr Scott McLean said: “I would like to reiterate our apologies to Mrs C and note the ombudsman’s comments that NHS Fife has taken action to prevent a repeat occurrence.”