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Management of work-related injury that progressed to cellulitis (03HDC02435)

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(03HDC02435, 26 August 2004)

Occupational health nurse ~ General practitioner ~ Leg injury ~ Standard of care ~ Co-operation among providers ~ Information about condition ~ Rights 4(1), 4(5), 6(1)(a)

A man working as a stockman for a regional food-processing company complained that an occupational health nurse and a general practitioner did not adequately assess injuries to his leg and refer him appropriately, or give him adequate information about his condition.

The man initially attended the company's health centre on the site of the meat works. He completed an accident register form reporting minor bruising to his right lower leg after a "knock" from a sheep the previous evening. He was assessed by a registered nurse, who recorded in the day book (but not his medical file) that he had been bitten in the left leg by a sheep and had a headache; his skin was not broken and there was no bruising. The man was given Panadol and had the next two days off work.

The following day he attended the medical centre again, but it was closed for a public holiday. He recorded in an accident register form that he had been hit on the leg that morning and had bruising. He did not consult one of the first aiders available when the centre was closed, or consult his GP or an after-hours medical centre. He returned to the company medical centre the next morning, and a first aider recorded on an accident register form that the previous day he had been hit by a sheep and sustained moderate bruising on his right lower leg, and it was slightly swollen, bruised and painful. The man was referred to the health and safety manager, an occupational health nurse who was consulted by first aiders on occupational health matters, although this was not in her employment contract. She observed that he had localised swelling but a good range of movement and was able to walk. Arnica cream was applied to the bruise, and the man was given a Voltaren tablet and a support bandage for his leg. She advised him to return in the afternoon or earlier for review; he did visit the medical centre but it was unattended at the time and he was not seen. He did not contact the occupational health nurse or the first aider, who were elsewhere on the site at the time. Signs explaining how to do so were evident at the medical centre, and employees were routinely advised of the procedure at their induction.

The man returned to the medical centre the following morning. The first aider noted increased swelling overnight and referred him to the occupational health nurse, who decided to refer him to the centre's GP. The GP recorded that the man's leg was very swollen and bruised, but he walked unaided with a slight limp; there was no evidence of abnormality in the knee and ankle, nor of a fracture. The GP did not take the man's temperature, as he did not appear unwell, toxic or feverish, and the skin did not appear broken or blistered. The GP recommended three days in bed with the leg elevated, and reassessment within the three days if needed. The man visited family and then returned home, where he wrapped a towel around his leg because it had started to weep, and went to bed. His wife found him semi-conscious the next morning and took him to a local medical centre, where he was found to have an infection in his lower leg and cellulitis in his foot. His temperature was slightly elevated and he was referred to hospital. He was initially treated with intravenous antibiotics, but the skin became necrotic, necessitating surgical debridement, and an abscess developed and required draining. He was discharged from hospital three weeks later.

It was held that the occupational health nurse did not breach the Code. She properly assessed and treated the man's leg and appropriately told him to return for review later in the day; at the time there was no clinical evidence of an infection and his condition did not warrant referral. She also promptly arranged for him to be assessed by the GP the following day when the swelling had increased, and provided adequate information to the GP.

The GP was also held not to have breached the Code in the care he provided and the information he gave to the man. At the time of the consultation there was no clinical evidence of infection or reason to suspect infection might occur; the infection developed very quickly and was not detectable until after the man's consultation with the GP. The man had been advised to return for reassessment if he was concerned about his condition.

The need for comprehensive documentation of workplace injuries and interventions was commented on, and it was recommended that the food-processing company clarify the role and responsibilities of the occupational health nurse.

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