We have secured settlement for a client whose ruptured Achilles tendon was misdiagnosed by A&E practitioners when she attended the emergency department at Epsom Hospital in August 2016. As a result of the misdiagnosis, our client’s injury was not managed and she mobilised on her injured Achilles tendon, causing her significant pain. Her injury was only diagnosed when she saw a private orthopaedic surgeon six months later.
Our client was an NHS patient and attended the A&E department of Epsom Hospital after experiencing a sharp and sudden snap at the back of her left leg: a classic sign of a ruptured Achilles tendon. She told the triage nurse and the emergency doctor of her history. Her left ankle was examined and a Simmonds test was performed. The Simmonds test was reported as being negative and the A&E doctor diagnosed a partially ruptured Achilles tendon. Our client was given a pair of crutches and she was discharged home. She was advised to rest, ice, compress and elevate her left leg and mobilise as her pain allowed. No imaging investigations were arranged and our client was not referred for a further opinion from an orthopaedic surgeon.
Our client followed the advice of the A&E doctor. She rested her ankle but continued walking to work every day, causing her considerable pain. Gradually, over time, her pain improved but she noticed that her left ankle was very weak. Her tolerance for standing and walking was reduced and she noticed some muscle wastage in her left calf. She arranged to see a private orthopaedic surgeon who immediately suspected a ruptured Achilles tendon. After some initial investigations, including imaging, he advised our client of her diagnosis. Our client was referred for physiotherapy to try to strengthen her left ankle but she was told that she might require surgery. She attended physiotherapy three times a week for seven months and gradually was able to improve the strength of her left ankle, but it remained weaker than her right ankle.
She approached us because she was concerned that she had completely ruptured her Achilles tendon in August 2016 and that there had been negligence in the management of her injury. She had experienced pain for a prolonged period and had put in significant effort only to improve her outcome slightly.
We accepted instructions and obtained evidence from an expert A&E doctor. That expert’s opinion was that the management of our client’s injured Achilles tendon was negligent. The A&E doctor should have immobilised her ankle and referred her to an orthopaedic surgeon. We then instructed an expert orthopaedic surgeon. His opinion was that our client had suffered a full rupture of her Achilles tendon. Had she been referred to an orthopaedic surgeon in August 2016, as she should have been, she would have been diagnosed, her left ankle would have been immobilised in an air cast boot and she would have been advised not to bear weight on her left leg. She would have had a good recovery and would not have had a permanently weakened left Achilles.
As a result of the A&E doctor’s failure, our client was left with a permanently weak left ankle. Despite recovering some strength through physiotherapy, she would never be able to regain the same level of strength that she had prior to the injury unless she underwent surgery.
After completing our investigations, we wrote to the NHS trust setting out the formal allegations of negligence that the medical experts supported. The letter of response from the trust admitted negligence but did not set out its case on the extent to which that negligence had caused our client an injury.
Further expert evidence was then obtained. The expert’s opinion was that, with acceptable management, our client’s left Achilles tendon would have healed and, after some physiotherapy, she would have recovered full strength in her ankle. She would not have needed surgery. It was alleged that, as a result of the admitted failures, our client suffered a prolonged recovery and a period of pain and suffering. Her left Achilles healed in a lengthened position, leaving her with a permanently weak left ankle. She would require some care and assistance in the future.
After negotiations with NHS Resolution for the defendant trust, by disclosing our expert evidence we were ultimately able to achieve a good settlement for our client.
It has recently been reported that delays, misdiagnosis and poor treatment in A&E departments are now the top cause of negligence claims in the UK.
This case is just one example of how failures in A&E to manage patients’ injuries appropriately can have quite significant consequences. Management of our client’s injury should have been straightforward. Instead, she experienced a prolonged recovery from her Achilles tendon injury during which she experienced pain and suffering, she incurred increased costs of paying for private healthcare, and she has been left with a permanent injury and impaired prognosis.
Diagnosing Achilles tendon ruptures
Rupture of the Achilles tendon is a common injury, with approximately 4,500 patients seeking medical help every year in the UK.
Patients who suffer an Achilles tendon rupture often present with a common history: a sudden pain in the back of the leg, with an audible snap. Patients will often think that they have been hit or kicked directly in the calf.
Ruptured Achilles tendons should be diagnosed by taking a careful history of the injury and performing an appropriate examination. This should involve looking at the ankle and Achilles tendon, checking for swelling and bruising, and feeling the Achilles tendon for a step gap in the tendon. Where an Achilles tendon rupture is suspected, the patient should be asked to see whether they are able to stand on their tiptoes and a test of the Achilles tendon, known as a Simmonds calf squeeze test, should be performed. This is best carried out with the patient kneeling on a chair or bench or lying on an examination couch. The doctor should squeeze gently the bulky part of the calf muscle. An uninjured Achilles tendon will move into a plantar flexion. An injured Achilles tendon will not move because the calf muscle is no longer connected to the foot.
However, these tests can result in false negatives; some patients with ruptured Achilles tendons will be able to go onto their tiptoes (on both feet together – though not on the injured limb alone) and the Simmonds test can result in some movement of the foot if the injury is not completely fresh and an element of healing has already occurred. In such situations, where the history is suggestive of a ruptured Achilles tendon but without conclusive investigations, the appropriate management is to assume the worst and arrange imaging investigations to confirm whether there is an injury, or immobilse the ankle and refer the patient to an orthopaedic surgeon for further investigation.