Page 21

21LEGAL MEDICOMAGAZINESponsored by:our experiences in the understanding of facial trauma mechanisms are to some extent flawed and could be challenged. As a matter of course, I do take patients’ stories with a small pinch of salt and I have wondered if other specialists have the same experience.Nevertheless, in some cases some conclusions can be drawn. Some types of laceration may give an indication as to the cause of the injury, for example whether the skin was cut or split. Similarly, the shape of a bruise, or split in the skin may indicate the type of blunt weapon used. Some wounds may also give an indication about the site of impact and direction of the force. But again, this is really forensics, not medicine. 5. Delays in diagnosis.Excessive delays in diagnosis and treatment may adversely impact on outcomes, for example treatments aimed at either salvaging teeth (such as replantation, or root canal therapy), or maintaining their cosmetic appearances. Similarly, significant delays in repairing facial wounds and fixing fractures can result in suboptimal outcomes. Over time, simple fractures become more difficult to treat. Understandably therefore, patients may not be too happy with the prospect of an extra surgical scar on their face, because a simple fracture was initially ‘missed’ and now requires more complex surgery. Similarly, If a tooth is ultimately lost the patient may feel there has been a shortfall in care by not diagnosing the problem sooner. That said, some patients need to take ownership of their injuries and act accordingly. Failing to attend follow up appointments is a common problem which immediately adds to any delay in management. Many hospitals have policies in place to discharge patients that fail to attend follow up appointments and this can result in significant delays, if patients then need to be re-referred. 'Choice' and 'partnership' are words commonly used by politicians and managers to empower patients. So, if a patient ‘chooses’ not to attend a pre-arranged (and agreed) follow up appointment, who is at fault if subsequent treatment then becomes more complicated?However, it is also important to remember that co-existing concussion, fatigue, alcohol and drugs (both analgesic and recreational) can impair anyone’s ability to retain information. Telling a very drunk patient to attend a follow up appointment may therefore result in non-attendance. Written instructions should therefore be given. Detained prisoners comprise another small but important group. Normally, with non-prisoners, review appointments are often given at the end of the consultation, but this practice may be deterred by the accompanying officers, so that the prisoner does not know. In my experience this (plus the lack of staff) can result in missed appointments and delays in follow up and treatment. In the second part of this article, to be published in the next issue, I will discuss the impact of NHS targets on treatment of facial trauma, as well as other issues such as patient consent, confidentiality, and compliance,– which could all arise in litigation.Michael can be contacted on: michaelperry@nhs.net