NHS Tayside was told to apologise to a patient after failing to identify she had a broken hip.
The blunder was made at Ninewells Hospital, with a misdiagnosis that the patient had strained a ligament in her knee, leaving her in pain for months.
The case came to light following a report by the Scottish Public Services Ombudsman (SPSO).
The report related to the treatment of the woman, described only as “Ms C”. Other failings were also found.
The report said the patient was reviewed by a consultant orthopaedic and trauma surgeon who diagnosed a strained ligament in her knee and she was subsequently referred for rehabilitation physiotherapy.
After experiencing “worsening pain” over a number of months, an X-ray was carried out and identified a hip fracture.
The report said: “We took independent advice from a consultant orthopaedic surgeon and a physiotherapist.
“Ms C noted that no X-ray was performed at the consultation with the surgeon.
“The board said that an appropriate examination was carried out and that this examination gave no indication that an X-ray was required.
“The orthopaedic surgeon adviser said the examination was not recorded in sufficient detail in Ms C’s medical record and that it provided inadequate evidence that a hip fracture was excluded.”
Further concerns were raised by the patient about her physiotherapy.
It was found there were “indications the initial diagnosis of ligament strain of the knee may have been incorrect”.
The report said there had “been a failure to re-evaluate the situation in light of Ms C’s increasing pain and deteriorating mobility”.
It added: “We considered that this contributed to the delay in identifying the hip fracture.
“Finally, we found that there were failings in recording of assessments and pain scores during these appointments.
“However, we noted that the board had acknowledged this failing and had taken steps to address this.
“Overall, we found the board unreasonably failed to identify Ms C’s hip fracture and upheld the complaint.”
A spokeswoman for NHS Tayside said: “We have apologised to the patient and have taken action to address the recommendations in the SPSO’s report.”