Complaint
The Medical Council was advised by the Accident Rehabilitation and Compensation Insurance Corporation (ACC) of a finding of medical error in relation to the treatment provided to the consumer. As required by the Medical Practitioners Act 1995 the Medical Council referred the matter to the Health and Disability Commissioner.
The complaint is that when the consumer was seen by the provider for an injury to her finger sustained in mid-September 1996, the provider did not provide appropriate treatment. In particular, the complaint is that on finding that the finger had been dislocated, the provider did not immediately refer the consumer to an orthopaedic surgeon and did not prescribe antibiotics.
Investigation
The referral was received on 26 June 1997 and an investigation undertaken.
Information was obtained from:
- The Provider/General Practitioner
- The Complainants (the consumer's parents)
- The Chief Executive Officer, Crown Health Enterprise
ACC provided all the documentation for the consumer's claim.
The Commissioner obtained advice from a General Practitioner.
Outcome of Investigation
In mid-September 1996 the consumer (two years old) jammed her finger in a door and was taken by her parents to the Emergency Department at the Hospital, where she was seen by the provider, a GP.
The provider examined the consumer's finger and states that he found there was a severe crush of the terminal phalanx of the right ring finger with a near amputation and a 75% circumferential laceration of the finger. He repositioned the terminal fragment and skin using Vaseline gauze strips and a dressing on the finger.
The provider saw the consumer for a follow up visit three days later and thought that although the finger tip was dusky, it appeared viable. On this visit the finger was x-rayed and the provider noted that the swelling had produced dislocation of the joint. The provider advised the Commissioner that he "made a decision on that appearance that an orthopaedic surgeon would not operate at that stage but wait for the swelling to go down and the blood supply to be more secure."M
The provider saw the consumer again three days later in the outpatient department and states that the viability of the terminal finger appeared satisfactory at this visit. The finger was redressed and the provider provided a letter for the family's GP, in another town. This letter notes the dislocation of the joint and the provider's thinking that "when the swelling has decreased and wound healed she could be seen by an [orthopaedic surgeon] in due course." On returning home the consumer's parents took her to their GP, ten days after the injury was sustained. This GP arranged an urgent referral to an Orthopaedic Surgeon.
When the Surgeon examined the consumer's finger he advised that surgery was required and that he would insert a 'K-wire' to reduce the fracture. The Surgeon operated on the consumer's finger in early October 1996 but due to infection and swelling present in the finger, he was unable to reduce the fracture with a 'K-Wire' at that time. The Surgeon carried out a second operation to insert the 'K-wire' three days later.
The consumer retained the tip of her finger but now has a deformity of the affected area.
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
RIGHT 4
Right to Services of an Appropriate Standard
2)Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Opinion: No Breach
Right 4(2)
In my opinion, there has not been a breach of Right 4(2) by the provider GP.
Referral to an Orthopaedic Surgeon
The provider's foremost concern was treatment of the soft tissue injury and maintenance of blood supply.
My general practitioner advisor stated that:
In my opinion manipulation of the finger could have interfered with blood supply and put the viability of the finger at risk. The provider's plan of action in regard to referral to an orthopaedic surgeon was reasonable in the circumstances.
Antibiotics
My general practitioner advisor further commented in respect of whether the provider should have prescribed antibiotics that:
My view is that where you have such a high amount of skin break where the bone is actually exposed to the outside, antibiotics are useful while in therapy but it is not necessarily that an inappropriate standard of care has been delivered by not prescribing antibiotics."
While prescribing antibiotics for the consumer may have been wise, in hindsight, by not prescribing antibiotics the provider did not fail to provide an appropriate standard of care. I accept the provider's comment that:
In my opinion the treatment provided by the provider to the consumer was reasonable in the circumstances, and therefore not in breach of the Code.
Suggestions
I have considered the comment by my general practitioner advisor that the view of a number of doctors may be that the type of injury suffered by the consumer would indicate that antibiotics were appropriate. While I have not found a breach of the Code of Rights in this case, I suggest that in future when the provider provides treatment for an injury such as that sustained by the consumer, he give due consideration to the option of providing antibiotic treatment to prevent infection.
Actions
A copy of this report will be sent to the complainants, ACC and the Medical Council of New Zealand.