Missed fractures in A&E: when delayed diagnosis may give rise to a medical negligence claim
A fracture is one of the most common injuries seen in accident and emergency departments, yet they continue to be missed every day across the NHS.
While many patients are diagnosed and treated appropriately, others are incorrectly reassured that they have suffered a sprain, strain or soft tissue injury, only to discover days, weeks or even months later that a broken bone has been overlooked. Unfortunately, delayed diagnosis can lead to avoidable pain, prolonged recovery, more invasive treatment and, in some cases, permanent disability.
Recognising the significance of this issue, NHS Resolution published its 2022 review into missed fractures, which examined medical negligence claims arising from fracture misdiagnosis in emergency departments across England and identified important lessons for healthcare providers.
How are fractures being missed?
Missed fractures can arise during the initial A&E assessment itself. Emergency clinicians are expected to take a thorough history, carry out an appropriate examination, assess whether a patient can weight bear or use the injured limb, and determine what investigations are required. Errors can occur when symptoms are underestimated, important clinical signs are overlooked, or a clinician prematurely concludes that an injury is minor. The NHS Resolution review identified shortcomings in assessment, training and clinical decision-making as recurring themes in missed fracture claims. Certain injuries, including hip, scaphoid, spinal and ankle fractures can be particularly challenging because symptoms may be significant despite apparently reassuring initial findings.
Radiological investigations are another common source of error. Although X-rays remain the first-line investigation for most suspected fractures, not all fractures are visible on plain radiographs. Some injuries are subtle, whilst others are better demonstrated on CT or MRI scans. A fracture may be missed because inappropriate imaging was requested, the images were incorrectly interpreted, or because a radiologist’s report identifying the injury was not acted upon by the treating team. NHS Resolution’s review found that communication failures, delayed reporting, and inadequate systems for recalling patients following revised radiology reports all featured in claims involving missed fractures.
How often is this happening?
The prevalence of this problem often comes as a surprise to patients. NHS Resolution considered missed fractures sufficiently common to devote an entire national thematic review to the issue. Earlier research examining diagnostic errors within a busy UK A&E department found that almost 80% of diagnostic errors involved missed fractures, with the most common causes being misinterpretation of X-rays and failure to arrange appropriate imaging. Other published studies have estimated that failure to diagnose fractures accounts for up to 80% of diagnostic errors occurring in emergency medicine, and that approximately 3% of fractures may initially be missed. These figures demonstrate that missed fractures are not isolated incidents, but represent one of the most frequent sources of medical negligence claims arising from emergency care.
What are the consequences?
The consequences of a missed fracture can be significant. A patient who might have recovered with a cast, brace or timely surgery may instead experience worsening displacement of the fracture, delayed healing, chronic pain or permanent loss of function. NHS Resolution’s thematic review paid particular attention to missed hip fractures, recognising that delays in diagnosis can substantially affect treatment options and outcomes. In some cases, patients lose the opportunity to undergo less invasive surgery and instead require complex procedures such as total hip replacement. The physical, emotional and financial consequences of these delays can be profound and long lasting.
Bringing a medical negligence claim for a missed fracture
If you have been informed that a fracture was missed following an A&E attendance, you may be entitled to pursue a medical negligence claim. If you have suffered ongoing pain, required additional treatment, or learned that a fracture was overlooked when you visited A&E, specialist medical negligence solicitors can help you understand whether you have grounds for a claim.
The medical negligence team at Penningtons Manches Cooper regularly investigates cases involving delayed fracture diagnoses, missed X-ray findings, and failures to arrange appropriate follow-up care. We can obtain and review medical records, instruct independent experts, and advise whether the delay in diagnosis caused avoidable injury and loss for which you may be entitled to claim compensation.
Case study – missed spinal fracture leading to foot drop
We acted for a client who attended A&E following a traumatic injury, and was discharged after a spinal fracture was not identified. The claimant continued to experience significant symptoms before it was eventually discovered that they had sustained an L3 vertebral fracture. By the time the correct diagnosis was made, the delay in treatment had resulted in neurological complications, including foot drop.
Our specialist medical negligence team conducted a detailed investigation, obtaining medical records and independent expert evidence from both a consultant in emergency medicine and a consultant spinal surgeon. The experts identified concerns regarding the assessment, diagnosis, and management of the injury during the initial A&E attendance and considered whether earlier diagnosis and treatment would have prevented the neurological complications that subsequently developed. The claim was put to the defendant NHS trust, which responded with a denial of liability. We challenged that denial and the claim subsequently settled.