Importance Of Gathering Information And Effective Communication Highlighted

A woman presented to a rural hospital emergency department following a fall that injured her thumb. She was seen by a triage nurse, followed by a medical officer who cleaned and sutured her wound, but no X-ray was taken.

Two weeks later the woman presented to another hospital where she was treated for an infection. She required surgery and developed arthritis in her thumb.

At the initial hospital visit the triage nurse documented "thumb swollen" and "bent back at time of injury." Despite differing recollections of the conversation about the injury, the doctor believed the injury was a laceration caused by a fall, and at the time was not aware of any issues with joint movement.

The Deputy Commissioner considered that the medical officer who initially treated the woman failed to provide services with reasonable care and skill because he did not obtain an adequate history in relation to the woman’s injury, and didn’t arrange for an X-ray.

"I am satisfied the doctor did not enquire fully into how the woman’s thumb was injured," said Dr Caldwell.

"It was the doctor’s responsibility to read the nursing triage notes and to obtain an adequate history of the fall and the mechanism of the injury."

The full report for case 19HDC01258 is available on the HDC website.

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