A case of fragmentation rather than integration

When Rose told the doctor, she hadn’t had an X-ray, they said “Well, from X -rays you had when it very first happened, I would imagine that it's completely healed by now.”
Despite explain that she was still in pain, she was discharged.
At the same appointment, she was also discharged from physiotherapy, despite having an appointment scheduled for the following week.
She was told to access community physiotherapy via her GP, commissioned by the Integrated Care Board. However, attempts to arrange physiotherapy were unsuccessful because the hospital system still showed her as being under the care of the fracture clinic. This prevented community physiotherapy from accepting her referral. As a result, Rose received no physiotherapy support during her recovery.

Deterioration and further injury

Without proper rehabilitation and still experiencing pain and instability, Rose suffered another fall a few weeks later. Her injured ankle gave way while she was trying to steady herself and she fell, hitting her head and breaking her shoulder.

She returned to hospital and was treated with a sling, but further issues arose. She later had to cancel a follow-up appointment due to flu and a chest infection and she was reassured that the appointment would be rearranged. She did not receive a new appointment letter through the post.

When she later contacted the service, she was told she had been recorded as a “Did Not Attend” and so had been discharged again.

Nine months later

Nine months after her first fall, she was invited to have an X-ray at the new Community Diagnostics Centre (CDC). The referral came from County Hospital, managed by UHNM. 

The person attending to her advised her to go to A&E. She can’t drive and didn’t want to sit for hours in the waiting room whilst in pain. 

So, Rose went to her GP who made an urgent referral back to fracture clinic and to community physiotherapy, but she is still waiting for appointments. The GP could not access the X-ray results at the appointment, days after Rose had been to the CDC.

Current situation

At the time of sharing her experience, Rose reported:

• Severe restriction in shoulder movement
• Ongoing limping and instability in her foot
• Significant limitations in daily activities, including:
  • Washing her hair
  • Cooking
  • Driving
  • Household tasks

She described feeling “completely left” without coordinated care.

Impact

Rose described the impact of her experience as:

• Prolonged physical pain and reduced mobility
• Loss of independence
• Emotional distress and anxiety about potential further procedures
• Difficulty managing daily life and caring responsibilities

What worked well

Rose was clear that many frontline staff were:

• Compassionate and professional
• Providing good care within their roles

She emphasised that the issue was not individual staff, but the system around them.

Key issues identified

Key Issues Identified

This case highlights several concerns about system fragmentation:

• Incorrect clinical decision-making (discharge based on the wrong X-ray)
• Poor communication between services
• Lack of shared information systems (e.g. GP unable to view imaging)
• Disjointed referral pathways
• Reliance on postal communication leading to missed appointments
• Patients falling between services with no clear accountability

Rose’s care involved multiple organisations, including hospital services, community diagnostics, and GP care, which did not appear to operate in a coordinated way.

Conclusion

Rose’s experience demonstrates the challenges patients can face when navigating a fragmented system, particularly when care crosses multiple providers.

Her case raises important questions about:

• How information is shared between services
• How patients are supported through transitions in care
• How systems ensure patients are not discharged prematurely or in error

Rose hopes her experience will help prevent similar situations happening to others.

*Rose is not their real name