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A young pedestrian who was knocked over by a cyclist was sent home from Accident and Emergency (A&E) with an undiagnosed fracture to her head after doctors failed to properly assess her, England’s Health Ombudsman has found.

The Parliamentary and Health Service Ombudsman (PHSO) is calling on hospitals to learn from and take action on mistakes. It follows a case where a serious head injury was missed and the Ombudsman is urging the NHS to take action to make sure patients are properly diagnosed and that they receive appropriate treatment as soon as possible. 

The woman, who is now 20 and wishes to remain anonymous, was hit by a cyclist while crossing a road in Exeter city centre on 7 December 2022. 

A member of the public took the then 18-year-old to the Royal Devon and Exeter Hospital, which is run by Royal Devon University Healthcare NHS Foundation Trust. 

She spent three hours in hospital with injuries including a three-centimetre cut on her forehead, facial swelling, loose and chipped teeth, pain in her neck, head, left hand and left hip, as well as feeling nauseous and lightheaded. 

Doctors glued the cut on her head and she was discharged with only verbal head injury advice. 

The following day, the complainant still felt nauseous, her face was more swollen, and she still had head, neck, and shoulder pain. 

The woman’s parents took her to the minor injury unit at the Royal South Hampshire Hospital and she was immediately referred to A&E at University of Southampton NHS Foundation Trust, where an X-ray and CT scan revealed a fracture to the front of her skull, a broken rib and extensive facial bruising.

The complaint was brought to PHSO by the woman’s parents on her behalf about the care she received from Royal Devon University Healthcare NHS Foundation Trust. 

She said her experience with the hospital had given her anxiety which in turn disrupted her university education. 

Our investigation found failings with how the Trust assessed the complainant’s head injury, and she should have been given written advice as well as verbal advice for what to do if her symptoms escalated when she was discharged.

Royal Devon University Healthcare NHS Foundation Trust has agreed to comply with the Ombudsman’s recommendations, including apologising to the complainant, acknowledging the failings and producing an action plan to explain how it will prevent the same mistakes happening again. 

The complainant’s mother said: 

“We were shocked and angry when we found out doctors had missed the fracture and broken rib. It felt like because she was a young person going into hospital, there was no-one to really advocate for her, no-one there to fight her cause. 

“They missed major red flags and I literally can’t comprehend it. I worked for the NHS for nine years, I’m a great advocate of the NHS, and yet I feel my daughter was so let down. 

“It is scary that she was discharged not knowing what to do and knowing something didn’t feel right. 

“She’s still suffering from the effects of her treatment now. It has affected her grades. She’s very anxious and stressed about things now.

“We are so grateful that the Ombudsman took this on and has held them to account. This absolutely should not happen again, and we can help prevent others going through the same situation.

“The service I received from the Ombudsman has been very good. The caseworker really understood the whole situation and kept us informed, he’s been excellent.” 

Parliamentary and Health Service Ombudsman Rebecca Hilsenrath said: 

“As well as the physical pain and discomfort from sustaining a head injury, this young woman has experienced subsequent ongoing disruption, including to her education, at a key time in her life. It is particularly important that head injuries are properly assessed and treated appropriately in good time. This patient manifested a range of symptoms of injury, was not taken seriously and was let down badly.

“When mistakes in healthcare occur, they must be acknowledged and appropriately addressed to ensure a better service in the future. Those who complain to us are motivated by a desire to prevent others from experiencing the same service failings.  Our investigations aim to encourage learning and service improvements and we hope the NHS will listen and learn from what has happened.”