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Continuity of care

01 January 2009

Mr R was a 60-year-old builder who had been retired for several years after suffering a myocardial infarction. For four years he had been under the care of Mr U, consultant urologist, for the treatment of symptoms of bladder outflow obstruction secondary to benign prostatic hyperplasia. His treatment consisted of dual therapy with an alpha adrenergic receptor blocker and 5-alpha reductase inhibitors, and he was reviewed every six months in Mr U’s outpatient clinic.

Mr R was diagnosed with a large colonic tumour. His general surgeon, Mr S, elected to perform a left hemicolectomy and, before this, as his left ureter would potentially be at risk during the procedure, he had a ureteric stent inserted. This was performed by Mr U. The intention was for the stent to be removed in five or six months’ time when he was fully recovered from the hemicolectomy. He would also continue to be reviewed regularly for his benign prostatic hyperplasia. Mr R underwent his left hemicolectomy and made an unremarkable recovery from the procedure.

Two months later, Mr U accepted a consultant post in another hospital, and another urologist, Mr F, was appointed in his place. He started work shortly afterwards but did not receive a formal handover of any of Mr U’s patients.

Several weeks after this he reviewed Mr R in his outpatient clinic. Mr R had a very sizeable set of case notes because of his multiple pathologies, both medical and surgical. Mr F briefly reviewed these files, noting his history of benign prostatic hyperplasia, but missed the notes on the insertion of the ureteric stent. As Mr R’s symptoms had been stable on his dual therapy for quite some time, Mr F decided to discharge him from the urology clinic and therefore no further appointments were arranged.

Twelve months later, Mr R consulted his GP complaining of left loin pain and frank haematuria. Urea and electrolyte levels were measured and showed slight elevation of both his urea and creatinine levels. Because of his symptoms, Mr R was offered a renal ultrasound and flexible cystoscopy.

Renal ultrasound demonstrated a slight hydronephrosis of the left kidney, and also the presence of the ureteric stent. At flexible cystoscopy, the distal end of the stent was visualised and was found to be encrusted with stone. Because of the degree of encrustation, Mr R was unable to undergo removal of the stent at the time of flexible cystoscopy and the stent was removed under general anaesthetic at a later date.

A claim was made against Mr U, Mr F and the hospital for failing to arrange earlier removal of the ureteric stent.

Expert opinion

Expert opinion was obtained from a consultant urologist. In his opinion, it had been Mr U’s responsibility to arrange a proper handover with Mr F. The expert commented that there was no reference in the urology section of Mr R's notes to the ureteric stent, nor to the intended follow-up (ie, the need for removal). The hospital was also criticised for failing to have a suitable handover procedure for such patients. The claim was settled for a low sum, which was shared between the urologists and the hospital.

Learning points

  • Mechanisms should be in place to ensure the safe handover of complex patients between consultants.
  • However arduous it may be to review thoroughly the notes of “inherited” patients, it is very important, and is especially so in complex cases.
  • For patients with a ureteric stent, clear marking of the notes is required to indicate when that stent should be removed (or indeed changed for patients with long-term ureteric stents). If Mr R’s notes had been annotated in this fashion, the circumstances of this claim might have been avoided.