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Management of wound caused by glass (01HDC04614)

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(01HDC04614, 24 September 2002)

Right to services of an appropriate standard ~ Reasonable care and skill ~ Compliance with professional and other standards ~ House officer ~ Emergency medicine ~ Laceration ~ Clinical examination ~ X-ray ~ Public hospital ~ Vicarious liability ~ Hospital protocols ~ Right 4(1) ~ Right 4(2) ~ Health and Disability Commissioner Act s 72

A complaint was made by the consumer's mother about the treatment provided to her son by a senior house officer at a public hospital. The complaint was that the senior house officer failed to X-ray a shin laceration and so missed a glass fragment, and failed to ascertain that the tendon was damaged.

The facts were that the consumer was involved in an accident where a thick sheet of glass was dropped and cut into his lower left leg. At the hospital emergency department no X-ray was taken to ascertain whether any glass fragments were lodged in the wound. The house officer conducted an examination and concluded that there had been no tendon damage and therefore did not request an ultrasound or MRI scan. The house officer's clinical notes state that the consumer was adamant that the glass could not have broken but it was found that the consumer did not refuse an X-ray. A later X-ray revealed that a glass fragment was lodged in the wound and an ultrasound confirmed that the tibialis anterior tendon was ruptured. The Emergency Department's 'Guideline on Wounds and Lacerations in General' states that wounds caused by glass must be X-rayed.

The Commissioner reasoned, after receiving independent expert advice from an emergency medicine consultant, that:

(1) the Emergency Department's 'Guideline on Wounds and Lacerations in General' required that wounds caused by glass must be X-rayed; and

(2) while ultrasound or MRI is required to image soft tissue defects this would not be considered as a first-line investigation unless the clinical suspicion was great.

The Commissioner held that:

(1) the house officer breached Right 4(2) of the Code by not complying with the Emergency Department's Guidelines, as it was the house officer's responsibility to insist on an X-ray being taken, and it was not reasonable to be persuaded by the consumer's statement that the glass did not break;

(2) the house officer did not breach Right 4(1) of the Code in failing to diagnose tendon damage, as the clinical notes demonstrate that he had conducted an appropriate examination for functional deficit and there was no clinical suspicion to warrant the taking of an ultrasound or MRI scan; and

(3) the public hospital was not vicariously liable as the clinical decision was not attributable to, or reasonably preventable by, the public hospital.