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A failure of communication

01 September 2009

Mr F was a 45-year-old taxi driver with a three-month history of neck pain and tingling in his left upper limb. After attending his general practitioner, the patient was referred to Dr W, a consultant neurologist.

On initial assessment, Dr W elicited the additional history of gradual onset motor weakness, which was now causing difficulties when changing gear. Examination confirmed unilateral sensory and motor deficit, with positive Hoffmann sign. Dr W arranged baseline blood tests and imaging. A biochemical and haematological screen was normal; MRI was reported as showing focal enlargement of the cervical cord consistent with an ependymoma. Mr F was referred to Mr A, a consultant neurosurgeon, for operative management.

Mr F consulted Mr A the following week. Mr A took time to explain the findings of the MRI, and proposed to perform a cervical laminectomy and removal of the tumour. He explained that, although the tumour appeared to be benign, he would need to confirm this intra-operatively with analysis of a frozen section. Mr F was then asked to sign a consent form, which listed complications including bleeding, infection, and damage to the spinal cord.

Mr F was admitted for surgery the following morning. The operation proceeded smoothly, the tumour was resectable and the histology of the frozen section was reported as benign. However, despite good haemostasis in theatre, on the patient’s return to the ward the dressing had soaked through with serosanguinous fluid and required changing. The ward staff were exceptionally busy with another patient and Mr A reviewed his patients alone on a postoperative round. Mr A recorded his review of Mr F in the medical notes as “19:30 - Awake. Obs stable. Dressing dry. Power 5/5 sensation normal bilaterally”.

The nursing notes for this period describe that the dressing was “soaking wet”, and had been changed twice in a little over two hours. Unfortunately, this information was never passed to Mr A, nor the junior doctor, Dr P, who was asked to review the patient overnight. It is recorded in the nursing notes that Dr P had reassured the patient, and asked for a clean gauze to be applied. There was no specific entry made in the medical records.

Mr A reviewed his patients the following morning before breakfast. Again, a dry dressing is noted, but this was not removed. Over the following five days, Mr A recorded that he checked the surgical wound three times. The nursing notes simply state “no bruising, no swelling”. No neurological examination was documented following the immediate postoperative period.

Mr F was discharged on the fifth postoperative day, but presented almost immediately to A&E with weakness and sensory loss distal to the surgical wound. MRI demonstrated a large haematoma in the soft tissue and a coexistent epidural haematoma, with consequent compression of the cord at C3-5.

Despite surgical evacuation, Mr F unfortunately remained quadriplegic. Solicitors acting for Mr F issued a claim against the hospital and Mr A. MPS settled the claim for a high sum, with a contribution from the hospital on behalf of the nursing staff.

Learning points

  • Communication within a clinical team is essential to maintain proper standards of patient care. This case highlights the difficulties which can arise when information is not passed between the nursing and medical teams. The lack of documentation of any neurological examination postoperatively was a further difficulty in defending this claim. 
  • The operation notes should always include postoperative instructions for early identification of any potential complications. Nursing staff cannot be expected to be familiar with every surgical procedure or the postoperative risks.
  • The preoperative consent process must be well documented. The written information on a consent form should be supplemented with a detailed discussion, and this conversation clearly documented in the clinical record.
  • It is good practice to ensure that patients receive a written account of the consultation and receive copies of correspondence between hospitals and primary care services.