A Clinical Risk Case Study- A Delay in Diagnosing a Rotator Cuff Injury

Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Mr Adam Rumian MD FRCS (Tr & Orth) Consultant Trauma and Orthopaedic Surgeon.

The Scene

The Claimant attended A&E after a fall, complaining of severe pain and loss of movement in the left shoulder. X rays were undertaken which showed no evidence of a bony injury. The Claimant was given a sling along with referral forms to the physiotherapy department which were handed in before being discharged.

The Claimant waited for 6 weeks to receive a physiotherapy appointment letter however, due to continued pain and limited mobility he went back to his GP who advised him that there had been an administration error and that the referral forms had been lost. The GP sent another referral form and arranged for a further ultrasound-scan to be performed.

The Claimant was finally seen by a physiotherapist, 8 weeks after obtaining his original injury, however, he was informed that treatment could not commence until a full diagnosis of the injury was obtained. A subsequent MRI scan was performed which identified a tendon tear and the Claimant was referred to the orthopaedic department.

The Claimant was seen by the orthopaedic team 7 weeks after referral and he was finally diagnosed with a rotator cuff tear with a secondary frozen shoulder.

The Claimant underwent a rotator cuff repair with subacromial decompression and manipulation.

TMLEP’s Independent Clinical Findings

TMLEP’s independent review identified instances of substandard care that resulted in the Claimant suffering a considerable delay in being referred to the correct department, a late diagnosis and a delay in undergoing surgery.

Upon review, it was clear that the administration error fell below the required standard of care and that the Claimant should have been seen by the physiotherapy team within 1-2 weeks from referral.

Diagnostic imaging would then have followed within a 4-week period and an urgent referral to the orthopaedic team made on the basis of serve shoulder pain and the presence of a rotator cuff tear.

The review highlighted that if the orthopaedic referral had been made in a timely manner (i.e. on an urgent basis) the Claimant would have been listed for surgical repair no later than 12 weeks after listing for surgery. Ultimately, the Claimant’s recovery period was delayed by approximately 3 months.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

-More robust administration system/processes to avoid referrals being lost – urgent physiotherapy referrals after injury should be treated as such and appointments made and communicated to the patient within 48 hours. Patients should be given contact details and instructions on how to chase this up as a failsafe.

-Patients presenting with a potentially significant soft tissue injury need to be given clear advice regarding the possible severity of these injuries, expected recovery times and when to seek medical treatment if symptoms fail to improve.

-In instances where a patient has severe pain after a shoulder injury and no fracture, a rotator cuff tear should be suspected. Local patient pathways should be established to prevent undue delay in diagnosis for an injury that may require surgical intervention.

To Conclude

Soft tissue injuries can be severe and have greater implications for future function if neglected than many fractures that would be routinely referred for specialist orthopaedic assessment.

A patient complaining of significant pain after an injury without a fracture should not be discharged without adequate arrangements for initial treatment. Robust local protocols need to be in place to ensure that they can easily access further specialist investigation and assessment directly if they fail to improve within a specified timeframe.

Consideration should be given to referring such patients directly to the orthopaedic team if an injury that may require surgical treatment is suspected.


Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Mr Adam Rumian MD FRCS (Tr & Orth) Consultant Trauma and Orthopaedic Surgeon. (2018). A Clinical Risk Case Study- A Delay in Diagnosing a Rotator Cuff Injury. TMLEP Clinical Risk Case Studies. 1 (8), 1.

Important Notice: This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0)203 355 9796.