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At the Doctor

Formal Complaint – Worcester Royal Hospital – May 11, 2006 A&E Visit

Mr. John Rostill
Chief Executive
Worcestershire Royal Hospital
Charles Hastings Way
Worcester WR5 1DD

Dear Mr. Rostill:

I am submitting, separately, a formal complaint about my visit to the A&E Department of the Worcester Royal Hospital on May 5, 2006.  During this 11+ hour stay in A&E, and despite x-rays and CAT scans, your colleagues failed to find my back fracture at T11.  I was misdiagnosed as having essentially bruised my bum, and was sent home with analgesics and told to try to “mobilise.”

The other complaint is at

Not surprisingly, the pain from my fractured back did not get better with the analgesics prescribed (Diazepam 10mg and DF118 30mg).  In fact, the latter caused severe constipation.  I can tell you that a fractured back and constipation are unbelievably horrible.

In the early afternoon of May 11, 2006 — my birthday — I couldn’t stand the pain any longer.  I called the St. John’s Surgery (our GP) and was told a doctor could see me now if I came “right over.”  My wife was at the grocery store, but returned within a few minutes of my telephone call to the GP’s surgery.  We rushed over to St. John’s, but were too late.  I told Marjorie that as I was dressed and out of the house, we should go (again) to the Worcester Royal Hospital A&E.

Big mistake.

My chart for this visit indicates “recent admission to A&E following fall. C/O increased pain especially around kidney in area.”  Claire Roberts gave me a triage category of 3 at 14:49.  Please fully explain this.  When I arrived by ambulance, on a guerney, having recently fallen, given morphine by the ambulance EMT’s and assigned a pain score of 9, and essentially unable to move I am given a triage category of 4.  When my wife, Marjorie, brings me back by car six days later and I walk into A&E, I am given a triage category of 3.

I can’t read the doctor’s notes, and no time is indicated.  Jane Clavey, in your Legal Department, provided me with a transcript on June 19, 2006.  The illegible notes are from Dr. Budhani.  He did not have on a name tag, nor did he introduce himself to me, or even indicate that he is a physician.

Dr. Budhani did a urinalysis — why was one not done during my previous visit?  Particularly because I said the pain felt a lot like kidney stone pain.  Is it not possible that a severe fall could have dislodged a kidney stone, or stones?  Aren’t urinalyses inexpensive and fast?  The urinalysis apparently showed “1 blood 1 protein.”  So Dr. Budhani prescribed Trimethoprim, which I understand (from Google) is used to eliminate bacteria that cause urinary tract infections.

At this time, in pain and frustrated, I asked to speak with someone to lodge a complaint.  Dr. Budhani wrote, “Patient wishes to see admin re: complaint.”

I was seen by Mr. Mulira.  I’d seen him once before in the A&E, on December 5, 2003, when the triage nurse at the time had problems cutting off my ring.  Mr. Mulira had been very helpful, arranged to have my hand x-rayed with the ring, and suggested squeezing a ball to remove the ring.  This worked perfectly.

Mr. Mulira’s notes on May 11, 2006 do not show a time, and are also difficult to read:

Mr. Mulira's Notes - 11 May 2006 

Again Ms. Clavey to the resuce with a transcript:

“Asked to see by Shiraz Budhani.  Many complaint.  I know Mr. Walsh of old. Needs AB and MSU done.  I will refer him to a urologist.  P.S. Wishes to see Duty Manager – Jo contacted.  Apollo Mulira.”

What does “many complaint” mean? 

Mr. Mulira’s referral letter to Mr. Chen dated May 15, 2006 — four days after my second A&E visit — seems to imply that I am a hypochondriac, running up and down the country to different  hospitals:

Mr. Mulira's Letter to Mr. Chen - May 15 2006

What exactly does “well known to Worcestershire Royal Hospital” mean?  At the time that Mr. Mulira wrote this letter, I’d been to the WRHl precisely three times during the 20 years I’ve lived in the U.K.:

  • December 5, 2003 (with a suspected broken finger)
  • May 5, 2006 (with a fractured back, that was misdiagnosed)
  • May 11, 2006.

None of these visits resulted in an admission.  This hardly makes me a regular customer!

Lost is the fact that I was in tremendous pain.   And when most people are in pain, they’re grumpy.  So far I’d spent 11+ hours in A&E on May 5, 2006 and been told I’d bruised myself.  I was given analgesics that caused severe constipation — and, therefore, yet more pain.  I’d been back to A&E (when I couldn’t see my own GP) and was now given a prescription for bacteria in my urine. 

When I made my appointment to see Mr. Chen, I called Ms. Clavey’s office and asked for a copy of my x-rays and CAT scans.  I explained that I needed this information as part of my continuing care:  I was concerned about the exposure to more x-rays (etc.) if new films had to be done.  In his June 26, 2006 report, Dr. Udeshi mentions that the CAT scans are a “high radiation dose examination  — that was his explanation for the fact that T11 was not included in the May 5, 2006 CAT scan films:

Dr. Udeshi Conclusion - June 26, 2006 Report

I was told by Ms. Clavey that my request for copies of my x-rays and CAT scan films would need to be handled as a data disclosure request, and that the process could take up to 40 days.  It did not matter to her that these films were needed as part of my continuing care — rules are rules.

An extract from Ms. Clavey’s letter to me of May 26, 2006:

Jane Clavey's Letter of May 26, 2006

In my effort to try to get copies of the x-rays and CAT scans earlier (so I could give them to Mr. Chen) I called your office and spoke with Sue Wood.  I asked Ms. Wood to please give me the contact details of someone in the radiology department.  Ms. Wood indicated that all of the personnel in radiology were “too busy” to speak with me, and that they were “treating other patients.”  I gently persisted — please remember that I was in pain — and Ms. Wood finally gave me Dr. Udeshi’s name and reluctantly transferred my call to his office.

It turned out that Dr. Udeshi wasn’t “too busy” after all — in fact, he was very helpful.  He explained that there was a written protocol to release films within five days when needed for continuing care.  He sent me a “Request for Copy Films” form, and a form for “Provision of Copy Images for Non-NHS Use.”  The “Request” form clearly indicates:

Five Day Rule

As Ms. Clavey is responsible for the disclosure of information, why was she not fully aware of this written protocol with its five day deadline?  And, more importantly, why didn’t she extend me the courtesy of trying to help me, rather than hiding behind the provisions of the Data Protection Act?

In my letter to Ms. Clavey of May 31, 2006 I wrote:

Letter to Ms. Clavey dated May 31, 2006

I wish to formally complain about the handling of my request for the x-rays and the CAT scan films.  I was made to essentially fight for them, which isn’t fair.  And then I am openly labelled as a complainer:  “Many complaints.”

There’s no empathy, no “there, there, let’s see what we can do to make it better.”  And that’s a shame.

But the story continues.  My separate, formal complaint about my May 12, 2006 visit to A&E at the Alexandra Hospital in Redditch is here:

Yours sincerely,

Craig W. Walsh