The Patient and the Plaster Cast

Abstract

In this series of case studies, serious adverse events that occurred in public hospitals are discussed with the aim of learning through other people’s experiences. They are also meant as a sober reminder that any one of us could err and that we need to exercise due care at all times. Some details of cases and all the names have been altered to protect the identity of patients and staff members, but all are based on real cases. In this case study, Mr Khumalo fractured his ankle. The fracture was stabilized by means of an internal screw and plate. A Plaster of Paris (POP) cast was applied and he was discharged two days later. Nine days after discharge he returned to hospital complaining of discomfort under his cast. The wound was found to be black, a debridement was done but the necrosis spread and he ultimately needed a below knee amputation.