Case report:

“Patient was admitted to ITU after an epileptic seizure. Patient states on regaining consciousness had bilateral shoulder pain. Patient says they and their mother mentioned this repeatedly to staff (nursing staff and doctors) about shoulder pain and concerns, and was repeatedly reassured. Chest x-ray showing bilateral shoulder dislocation. Injury was missed. Injury only picked up by MRI 6 months later by which time severe damage to left shoulder. Affected patient's study and work. Patient will now require complex surgery and will likely suffer long term disability.”

Commentary:

The cause of unexpected or unexplained pain should always be sought. It's not clear exactly when the chest X-ray was taken, nor if and when it was formally reported. Although this case came to light in ICU, it could plausibly have come to light in post-anaesthesia recovery for instance and thus is a valuable lesson for us all.