Setting the Scene
An elderly patient attended A&E after suffering a fall where they hit their head. An x-ray of the patient’s shoulder was taken, and a dressing was applied to their forehead. The patient was discharged without a CT scan and/or MRI scan of their spine being taken. 10 days later, the patient re-presented via FAST positive ambulance transfer with signs of bilateral weakness. They were initially treated as a suspected stroke, however a CT scan later confirmed that they had suffered a cervical spine fracture. The fracture severely limited chest physiotherapy and consequently the patient passed away. The cause of death was bronchopneumonia.
The main learning points from this review stem from the following events:
1) Despite presenting with a head injury and complaining of neck pain, no CT scan and/or MRI scan was taken of the patient’s spine before they were discharged home.
2) The patient’s neck was not immobilised even though they were at a high risk of suffering from a cervical spine injury.
3) NG41 Clinical Guidelines for Spinal Injury Assessment and Initial Management were not followed.
4) When the patient re-attended the same A&E Department with bilateral weakness and neurological changes there was no suspicion that this may be due to the patient’s recent fall.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
When a patient over the age of 65 presents to A&E with reported pain in the cervical spine following a fall, a full in-line spinal immobilisation should be carried out to ensure the spine is protected whilst imaging is requested. A patient over the age of 65 is deemed to be at a heightened risk of sustaining a spinal injury according to NICE guidance NG41 and following this procedure is the most effective method for increasing patient safety until a diagnosis has been confirmed.
The presentation of bilateral weakness is unusual (though not impossible) for a diagnosis of a stroke. Therefore, it is important that Clinicians in A&E consider a patient’s medical history and, especially where there has been a recent fall, undertake a more detailed examination of the patient’s symptoms to establish the most probable cause and diagnosis.
- Updating Trust Guidance to incorporate NICE guidance on cervical spinal injuries is vital in ensuring a coherent standard of safe practice is being adopted across the board. Further training should also be provided if necessary, to guarantee that all staff involved in the patient’s care are aware of any changes in the most appropriate treatment that should be provided. For example, treating Clinicans should be aware that in elderly patients particularly, the use of a collar may not be indicated, especially if they have pre-existing vertebral disease (e.g. ankylosing spondylitis).
The patient’s increased risk factors for suffering from a spinal injury, in particular, their age and recent history of suffering a fall were not acknowledged and acted upon in a timely manner. In light of the patient’s risk factors they should have had a full in-line spinal immobilisation to ensure their spine was protected whilst relevant imaging was carried out. This would have confirmed that they had suffered a cervical spinal fracture and the correct treatment would have been commenced immediately.
Identifying the particular factors that put elderly patients at a heightened risk of suffering spinal injury is pivotal to ensuring that there is a safe practice of care in place. NICE guidance NG41 emphasises the importance of the assessment and early management of spinal injuries in pre-hospital settings and this guidance should be adopted to improve the quality of emergency and urgent care and to reduce patient death and disability
It is therefore crucial that Trust’s regularly cross-check their own guidelines to ensure they are in line with relevant NICE guidance. This will ensure that the Trust is providing the most appropriate standard of care which will inevitably enhance patient safety.