"Some very good care at Airedale A&E for broken ankle, but missed the medical side"

About: Airedale General Hospital / Accident and emergency Airedale General Hospital / Endocrinology Yorkshire Ambulance Service NHS Trust / Emergency ambulance

(as the patient),

I managed to break my ankle, and was treated at Airedale's A&E.

The paramedics were excellent, and took great care to keep my obviously broken ankle elevated throughout the trip to hospital. On arrival at A&E I was then put into a wheelchair where I couldn't keep my foot up, which wasn't ideal and seems like a problem that must occur with a lot of patients.

The x-ray department had a long queue, partly due to the number of patients and partly because they were training a new x-ray technician or radiographer, but once I got in there they were very thorough and lovely.

After the break was confirmed the staff pulled out the stops to get me through the plaster room and on to physio just in time for closing, so that I could get some lessons about using my crutches. This was all very efficient and the staff I met were all friendly.

However, I had let them know that I have Addison's and insulin-dependent diabetes. In significant illness or injury, Addison's is life-threatening because your body can't produce the hormones required to respond to the shock. I had taken my own emergency steroid injection as soon as the injury happened, and the ambulance had given me IV fluids, which helped. But at A&E they seemed not to realise that I could be unstable medically as a result of a broken ankle. No extra blood sugar readings were taken - of course I carried on monitoring myself, but the shock in Addison's can cause hypoglycaemia, which can be tricky to notice if you have a distracting injury.

The most important measure in Addison's is blood pressure - which should be done as an orthostatic measurement - so, sitting and then standing, as it's an orthostatic collapse that tends to come first in an adrenal crisis.

I appreciate that I could have brought any of this to their attention, but until I was discharged I assumed that I would see a Dr before discharge. The Nurse Practitioner who was taking care of me clearly knew what she was doing for a broken ankle, but as nurses are not trained in Addison's / Adrenal Insufficiency I don't think the seriousness of the situation was apparent to her. A steroid injection only lasts 4-6 hours, and it's necessary to monitor electrolytes as well as you can develop a sodium / potassium imbalance very quickly, especially with the insulin dependent diabetes as well.

I normally attend A&E at St James's in Leeds because all my endocrinology care is done there. I'm invariably assessed in majors by a fairly experienced doctor, and routinely get U&Es, multiple BP readings (one reading from the ambulance doesn't tell you anything as the BP can fluctuate), multiple blood sugar readings and usually an ECG. I asked the ambulance to take me to Leeds but they could only take me to Airedale.

It's not Airedale's fault that they're a small hospital, and it's not the nurse's fault that she hasn't been trained in Addison's, but it's one of those things where even a medical student would say "Adrenal crisis... uh oh! " Especially in the presence of diabetes.

I should have asked to see a Dr, but I also should have been asked if I needed to see one, given the number of serious medical conditions I have. I also should have said that I'm under the unplanned admissions avoidance DES and so my GPs would be available to advice - but again I wasn't asked and I was rather distracted by my broken ankle.

I'm sure I was also partly just keen to get home as I'm not a fan of being kept in hospital. I'm extremely good at managing my care, and I think the nurse and paramedics appreciated this and it almost certainly influenced them. They were correct to assess that I was competent, and I also felt that once discharged from Airedale with my ankle stable I could always get to Leeds if things started to go down hill medically. So far I seem to be continuing to manage fine, but most patients with adrenal problems wouldn't be able to continue a regime of 4-6 hourly steroid injections confidently at home, so it's 'normal' to be admitted for this. I'm happy to be not admitted, but this feels like it was not because my ability to self-manage was considered but because the awareness of the seriousness of Addison's with a significant injury just wasn't in place. I know it's a rare condition, but that's why all patients with rare conditions should be asked "do you think you need to see a Doctor as well? " The doctor and I could have had a conversation about what tests were needed to confirm that I was safe to go home. It's probably going to be fine, but that's down to luck rather than judgement. I did tell the nurse that I had access to specialist nurses for both my Addison's and Diabetes on the phone during office hours, and that I have great GPs, but it was 5pm on Friday so that's not available until Monday.

Clearly there's responsibility on both sides in these situations, so I hold my hands up to not having been 'demanding' enough - but at Airedale it does always feel like you're making a demand (being a nuisance), where at other hospitals locally I'm asked directly what kind of care I think I need and whether there's anything else I think they should be doing. I'd put this difference down to the building work chaos except that I've come up against it long before the building works began, and met it bringing relatives in as well as attending for myself, so it seems like a deeper cultural problem in the A&E department at Airedale which I don't meet at St James's or Harrogate. Perhaps nobody wants to ask for fear that they can't meet what the patient then might ask for? (Or at least not within the 4 hour window. )

I realise that asking all patients who have been triaged to minors whether they think they need to see a doctor isn't viable as many would say yes unnecessarily, not realising that the NP is very experienced with their type of injury. Perhaps just "have you been to hospital a lot recent? " and "what do they usually do for you there? " would have been good - I'd told them very clearly that I "always" go to Leeds because most of my specialists are there.

On the plus side, there was a lot of good hello-my-name-is, with staff introducing themselves. The few who forgot were happy to tell me when I asked them, and being trained properly to use my crutches, including stairs, was a very good thing. The current situation with building works isn't easy for staff or patients and generally the department didn't feel like it was in chaos and staff seemed to be in a pretty good mood, which was also nice to see.

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Response from Karen Dunwoodie, Patient Experience Lead, Airedale NHS Foundation Trust

Thank you for sharing your recent experience whilst a patient at Airedale’s Emergency Department.

We are pleased that your experience was mostly positive but would very much like to discuss with you the issues raised where you feel greater attention could have been given.

Please telephone our Patient Advice and Liaison Service (PALS) on 01535 294019 so that arrangements can be made to look into this further.

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Response from Yorkshire Ambulance Service NHS Trust

We appreciate this positive feedback about the Yorkshire Ambulance Service and our staff.

If you would like to pass on your comments to the individual ambulance staff who cared for you we will be able to identify them if you could pass on details such as the date and full address of where the incident took place. If you would like to do this please contact our Patient Relations department, email: patient.relations@yas.nhs.uk or telephone 0345 1220535.

We hope you are recovering well.

Best wishes.