Recurring concern

Inadequate clinical guidance for fracture management

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First reported 12 Dec 2017•Latest report 21 Oct 2024

Definition

What this concern includes

Includes deficiencies in national, professional or local clinical guidance specifically intended to support assessment, monitoring, pain management or treatment of fractures, including guidance gaps for elderly femur fractures and high-risk fractures managed conservatively.

Not included

Excludes failures to diagnose or treat an individual fracture where no clinical-guidance deficiency is identified.
Excludes guidance deficiencies for non-fracture conditions, even when they concern similar clinical decision-making or NICE guidance.
Excludes generic failures to follow existing fracture guidance where the guidance itself is adequate and the unsafe condition is non-compliance.
Excludes generic staffing, training, service-capacity or orthogeriatric-access deficiencies unless the reported deficiency is specifically the absence, insufficiency or inconsistency of fracture-management guidance.

Reports: 3
Individual concerns: 3
Date range: 2017–2024
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

National Institute for Health and Care Excellence1

NHS England1

St Giles1

University Hospitals Birmingham NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

21 Oct2024
Suffolk
Concerns raised1
1. Failure of NICE guidance to reflect up-to-date evidence on duration of post-surgical anticoagulation after hip-fracture surgery
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Monitor new evidence on prophylaxis duration and consider sufficiently robust findings through a surveillance review.
  Stated by National Institute for Health and Care ExcellenceStated in progress
Respondent positions 2
1. Position
  Decisions to continue or discontinue anticoagulation after surgery remain matters for clinicians’ individual assessment and clinical judgement.
  Stated by National Institute for Health and Care ExcellenceRedirects responsibility
1. Position
  Insufficient international consensus and evidence currently prevent extending guidance on prophylaxis duration and possible mesenteric thrombosis; new evidence will be monitored.
  Stated by National Institute for Health and Care ExcellenceUnable to act
AI-generated summary

Brian BEER · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Brian Beer died peacefully in hospital on 1 March 2024 from small bowel ischaemia caused by a superior mesenteric artery blood clot, following hip fracture surgery after an unwitnessed fall. The principal concern was whether current NICE guidance on the duration of post-surgical prophylactic anticoagulation adequately reflects emerging evidence about risks after hip-fracture surgery, particularly in immobile and elderly patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of NICE guidance to reflect up-to-date evidence on duration of post-surgical anticoagulation after hip-fracture surgery
Wider context from the report
“If NICE guidelines as to prophylactic anti-coagulation after surgery on a hip fracture do not reflect the most up-to-date international learning, then there is a risk of future deaths being contributed to by hospitals following NICE guidelines when a longer period of anti-coagulation post-surgery would better protect them against recognised complications of the surgery. ”
Source location
Brian BEER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor new evidence on prophylaxis duration and consider sufficiently robust findings through a surveillance review.

Verbatim wording from the response
“In line with the expert haematologist and her colleagues, we are not aware of evolving international consensus over the length of time for prophylaxis after a fractured neck of femur and the possibility of mesenteric thrombosis. NICE will continue to monitor new”

Source location
Response from National Institute of Health and Care Excellence
Page 1 · response
Published 21 October 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Decisions to continue or discontinue anticoagulation after surgery remain matters for clinicians’ individual assessment and clinical judgement.

Verbatim wording from the response
“The decision whether to continue or discontinue anti-coagulation would be a matter for clinical judgement based on careful assessment of an individual patient and their progress after surgery.”

Source location
Response from National Institute of Health and Care Excellence
Page 1 · response
Published 21 October 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Insufficient international consensus and evidence currently prevent extending guidance on prophylaxis duration and possible mesenteric thrombosis; new evidence will be monitored.

Verbatim wording from the response
“In line with the expert haematologist and her colleagues, we are not aware of evolving international consensus over the length of time for prophylaxis after a fractured neck of femur and the possibility of mesenteric thrombosis. NICE will continue to monitor new”

Source location
Response from National Institute of Health and Care Excellence
Page 1 · response
Published 21 October 2024
Open published response
23 Aug2021
Manchester South
Concerns raised1
1. Lack of NICE guidance for consistent management of femur fractures in elderly patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  There is not a lack of guidance on periprosthetic femoral fracture treatment, fracture pain management or palliative care.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Maurice Leech · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of NICE guidance for consistent management of femur fractures in elderly patients
Wider context from the report
“3. The inquest heard that he was in significant pain from the fracture to the femur. Unlike the position relating to a fracture to the neck of femur there is no NICE guidance for treatment of such fractures to ensure a consistent approach to management of them in the elderly across the NHS. This included in Mr Leech’s case how to effectively manage his pain and the impact of that on his overall health. ”
Source location
Maurice Leech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
There is not a lack of guidance on periprosthetic femoral fracture treatment, fracture pain management or palliative care.

Verbatim wording from the response
“In relation to your concern about guidance for the treatment of fractures to the femur, you may wish to note that while NICE Clinical Guideline 124: Hip fracture: management⁴, does not make specific recommendations on the management of this type of fracture (periprosthetic), it does cover the use of analgesia (see section 1.4) and multidisciplinary management (section 1.8) of people with hip fracture. I am advised by NICE that it is reasonable to expect that Clinical Guideline 124 could be applied to people with periprosthetic femoral fracture, such as Mr Leech.”

Source location
2021-0279-Response-from-Department-of-Health-Social-Care_Published.pdf
Page 3 · response
Published 26 August 2021
Open published response
12 Dec2017
Birmingham and Solihull
Concerns raised1
1. Lack of clear guidelines for managing high risk fractures treated conservatively
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
2. Action
  Disseminate interim guidance on conservatively managed potentially unstable fractures to Trauma and Orthopaedics clinicians.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
AI-generated summary

Francis Robert Beech · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear guidelines for managing high risk fractures treated conservatively
Wider context from the report
“1. Lack of clear guidelines regarding the management of high risk fractures treated conservatively. I heard evidence that this was a high risk fracture as there were sharp edges and little skin over the ankle area. The deceased required regular monitoring as a result. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.

Verbatim wording from the response
“Following the findings from this report, guidelines will be formulated for clinicians to follow for these patients. These will include recommended timescales for follow-up and x-ray reviews to be used in conjunction with clinical judgement. The new guidelines will be called ‘Conservative Management of Unstable Fractures’ and will be implemented by the Trust by 31 March 2018. Once the guideline has been implemented, the Directorate will audit compliance. If you would like to see the guidelines, please let me know.”

Source location
2017-0367-Responses
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate interim guidance on conservatively managed potentially unstable fractures to Trauma and Orthopaedics clinicians.

Verbatim wording from the response
“The Clinical Director for Trauma and Orthopaedics has disseminated interim guidance to the department whilst the guidelines are being developed.”

Source location
2017-0367-Responses
Page 1 · response
Published 11 February 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of NICE guidance to reflect up-to-date evidence on duration of post-surgical anticoagulation after hip-fracture surgery

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of NICE guidance for consistent management of femur fractures in elderly patients

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clear guidelines for managing high risk fractures treated conservatively

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Respondent positions 2

Respondent positions 1

Actions described in response 2