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Failure to conduct adequate medical assessment

Failure to conduct an adequate medical assessment and order an x-ray

Health and Disability Commissioner Anthony Hill today released a report finding a doctor at an urgent care clinic in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to conduct an adequate medical assessment or organise an x-ray for a woman.

The woman went to the urgent care clinic after a fall at home the previous day. When the doctor examined her, the woman remained seated or standing with support. This meant that the doctor failed to assess the extent of the woman’s reduced range of movement adequately, and her inability to weight bear. Believing that there was no serious injury, the doctor prescribed analgesia and told the woman that she could travel by car to a family gathering in another city the following day.

The woman travelled to the gathering, but experienced excruciating pain in her hip. She was taken by ambulance to a public hospital, where an X-ray showed her hip was broken, which ultimately required a total hip joint replacement.

Mr Hill was critical that the doctor failed to complete the necessary and basic elements of a hip examination, including failing to organise an x-ray.

"Had an adequate examination of [the woman’s] hip occurred, a more accurate clinical picture would have emerged, and [her] fracture may have been identified earlier," Mr Hill said.

Following recommendations from HDC, the doctor has apologised to the woman and her family and told HDC she has reflected on the complaint and learnt from it. Mr Hill recommended that the doctor also prepare an anonymised case study for training purposes.

The full report for case 18HDC01962 is available on the HDC website.

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