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Over to you


We welcome all contributions to Over to you. We reserve the right to edit submissions. Please address correspondence to: Casebook, MPS, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK. Email: casebook@mps.org.uk

Cutting corners

As an anaesthetist, I was interested to read the case report “Cutting corners”, describing the severe brain damage that befell a four-year-old boy following an anaesthetic mishap (Casebook 22 (1)).

Over to you cutting corners The anaesthetist, Dr B, was criticised on several aspects of his care, including failing to warn the child’s parents of “the risks of anaesthesia”. I should like to know what MPS recommends in this regard, given that in the case quoted, the child was fit and well, with no medical problems or allergies, and was appropriately fasted. He obviously required a general anaesthetic, and in the overwhelming majority of such cases, one would expect this to be uneventful. What should Dr B have told the parents, without alarming them unnecessarily?

Dr Ian R Fletcher
Consultant anaesthetist, Newcastle upon Tyne, UK

Response

We have had several letters in relation to the issue of consent to anaesthesia in this case, and specifically the issue of warning of the risks associated with anaesthesia. It is fair to say that the medicolegal landscape does change with time, and can be dependent on the jurisdiction. The general trend, however, is towards a full disclosure of risk, and a process of joint decision-making with the patient (or in this case, the parents). In respect of rare but serious complications such as awareness, nerve injury, disability and death, the AAGBI (Association of Anaesthetists of Great Britain and Ireland) recommend in their guidance Consent for Anaesthesia Revised Edition 2006 (para 5.3.8), that written information should be provided, and the anaesthetist should be prepared to discuss the risks.

A catalogue of errors

As an orthopaedic surgeon, I was concerned about the number of cases related to orthopaedic surgeons in Casebook 22(1), January 2014. I was pleased to see, however, that many of these have been defended. What surprised me was the case “A catalogue of errors”. In that case, a lady underwent a knee replacement that appears to have been mis-positioned, which caused pain in the knee and the need for a revision procedure to be carried out at an early stage.

At that revision, carried out by a different surgeon, swabs were taken showing coagulase negative staphylococcus, but this was not thought to be significant. Subsequently, the patient developed an infected knee replacement and staphylococcus epidermis was grown (the same bacteria as coagulase negative staphylococcus). This pattern of late clinical symptoms from infection is not at all unusual with this low virulence organism. The importance of this, of course, is that the infection was clearly in the knee following the initial operation and would have become symptomatic in due course in any event.

The infection would not have been a breach of duty as it is a well-recognised risk following any knee replacement, and this would have required a two-stage revision

The patient would therefore have required a revision knee replacement for this infection, even if the original components had been perfectly placed. I note that the first surgeon was sued and the claim was settled because of the poor technical skill exhibited in carrying out the original knee replacement, and your expert, Mr D, felt that this was a breach of duty which indeed it may well have been. However, the infection would not have been a breach of duty as it is a well-recognised risk following any knee replacement, and this would have required a two-stage revision in any event.

I note that the claim was settled for a substantial sum but it would seem that the main fault is misplacing the original component and then one revision procedure, rather than the eventual poor result with persistent pain, which is almost certainly due to the infection and consequence of scarring rather than anything to do with the original surgical procedure.

Professor Robert J Grimer
Consultant orthopaedic surgeon, Honorary professor, University of Birmingham, UK

Response

Thank you for your observations on this case. The expert in this case did carefully consider the issue of causation, and in particular the question of the infection that developed in the knee. His opinion was that the infection would not have developed if the patient had not required early revision surgery due to the substandard index operation. He was also of the opinion that had the initial procedure been carried out appropriately, the prosthesis would not have needed revision until it failed – in approximately 15 to 20 years. The settlement in this case reflected these issues.

Anatomy of a claim

In Casebook 22(1), January 2014, the feature “Anatomy of a claim” tells a depressingly familiar story.

Frequently and incorrectly termed “discitis”, infections of the vertebral bodies are commonly missed clinically. The vascular anatomy in the juxta-discal area shows a pattern of end vessels throughout life – hence a vulnerability to infection. The disc is avascular and infection can only occur by direct innoculation, eg, during surgery or discography.

In cases of thoracic spinal infection and in my experience of more than 35 years as a spinal surgeon, careful clinical examination of the spine will invariably disclose clear evidence. Pain and tenderness on local pressure will always be associated with the back pain history. Chest pain or radicular pain may also be present. The ESR is invariably raised.

Given the typical history given by Mr P, Dr C’s conclusion that the symptoms represented “muscular back pain” was made on the basis of symptoms that must have been present for more than ten days’ duration, and this was Mr P’s third consultation. Events showed this to be a serious misjudgment. Dr A’s second consultation (Mr P’s fourth) 25 days after his original assessment, with an increase in symptomatology and in the absence of a diagnosis, resulted in an entirely inappropriate referral for physiotherapy. This treatment is likely to have caused the onset of neurological symptoms six days later.

The subsequent surgical investigation and operative treatment was both inappropriate and negligent, and therein lay the liability and causation

Mr P was noted to have a loss of sensation in his legs at the time of hospital admission. An MRI scan undertaken at another hospital disclosed an “infective discitis at T5-6”. Two laminectomies were undertaken, following which Mr P was rendered paraplegic. Laminectomy has been recognised as contraindicated as a surgical procedure for infections of the thoracic vertebral bodies for over 100 years. The history indicates that the laminectomy directly resulted in the complete spinal cord injury in Mr P at T4 (at least one level higher than the bony pathology). If the indication for surgery existed, a closed biopsy followed by an anterior debridement via a thoracotomy or an approach via a costo-transversectomy should have been undertaken. A majority of cases can be managed by appropriate antibiotic treatment.

If Mr P’s legal advisers had instructed experts who were familiar with the presentation and appropriate treatment of spinal infections, the outcome would have been very different. On the basis of the history, the claim that Drs A and C failed to suspect a spinal infection or arrange correct investigation that should have necessitated an urgent referral meant that Mr P’s claim is self-evidently correct. This was a failure of duty of care. The subsequent surgical investigation and operative treatment was both inappropriate and negligent, and therein lay the liability and causation. This should have been recognised by Drs D, E and G, and Mr F, had they been familiar with the extensive surgical literature on the subject.1

With correct clinical management, Mr P’s catastrophic outcome was avoidable. The case may represent a satisfactory outcome for MPS but it also represents a grossly unfair outcome for the patient/claimant.

Alistair G Thompson
Consultant Orthopaedic Spinal Surgeon, Birmingham, UK

References
  1. Bridwell KH and De Walt RL (eds), Textbook of Spinal Surgery (2nd Edition), Philadelphia: Lippincott-Raven (1997)
Response

Thank you for your comments on this article. In this case it is important to note that in this case the claimant did not bring any allegations in respect of the surgical treatment provided. The allegations were in respect of Drs A, B and C who saw Mr P at the GP surgery.

At trial it was clear that Mr P had no real recollection of what he had told the GPs about his symptoms during the various consultations

In accordance with the general principles of medical negligence, the standard on which the three doctors are judged is that of the reasonable general practitioners. On the doctors’ account of the case the GP expert evidence was supportive. Although there was a potential conflict of factual evidence (ie, what actually happened in the consultations), at trial it was clear that Mr P had no real recollection of what he had told the GPs about his symptoms during the various consultations.

Whilst an assessment at the beginning of the process by a specialist might potentially have resulted in an earlier diagnosis (depending on what symptoms were actually present), the standard to be applied is that of the reasonable GP, and our expert was clear that doctors A, B and C had reached that standard.

Consent templates?

The question of adequate consent and the preoperative discussion of possible risks and complications frequently appear in Casebook. Are there any templates of consent forms available for gynaecological procedures (especially laparoscopic procedures)? Is it not something that MPS should be involved in creating or developing?

Dr AA Carolissen
Gynaecologist, South Africa

Response

Thank you for your observations and comments. MPS does not produce specific templates or forms for use in the consent process. Consent is a process that will vary depending on the circumstances. Although there are some specific exceptions in relation to certain procedures, interventions and circumstances (eg, sterilisation and termination of pregnancy, which require the completion of statutory forms), the actual format of the consent is less important than the accurate documentation of the process. MPS has produced a comprehensive guide – Consent to Medical Treatment in South Africa – which is available on our website.

Controlled drugs

(This letter refers to an article in the New Zealand edition of Casebook entitled Controlled drugs: What you need to know)

Thank you for another informative issue of Casebook. I am responding to Helen Moriarty’s article on controlled drug prescribing (“Controlled drugs – what you need to know”, Casebook 22(1)) in New Zealand.

It is a widespread convention that locums (if not colleagues) are authorised to do all that the doctor they are replacing would normally manage, including prescribing to this category of patient

The article is clear and helpful, and the message that prescribing to any dependant person must be by a gazetted practitioner (and sometimes location) or under the specific written authority of such a practitioner, is clear. However, the article does not address the question of colleague or locum prescribing, and I have wondered about this in the past. Specifically, if the duly gazetted authorised practitioner is away/unavailable (not just fully booked that day), does a colleague from the practice, or a locum, have the legal right to prescribe for dependant patients?

It is a widespread convention that locums (if not colleagues) are authorised to do all that the doctor they are replacing would normally manage, including prescribing to this category of patient. I shall be grateful for Dr Moriarty’s further advice.

Dr Crispin Langston
Waimate, New Zealand

Response

Restriction Notices always specify “Doctor (name) or Locum” for this specific reason. You should find that this is the standard wording on Restriction Notices held in the practices that you work in.

How reliable is healthcare?

I’d just like to compliment the excellent article “How Reliable is Healthcare?” by Dr Dan Cohen in the current (January 2014) issue of Casebook. As both an airline captain and former surgeon, I have a view from both sides of the debate. I’d like to agree with his views on complacency leading to errors but must disagree on two points.

While I agree that patients are infinitely more complex than aeroplanes, the important point is that aeroplanes (patients) generally don’t cause accidents – it’s caused by human error due to the operator (healthcare professional or pilot). Therefore this is where we need to focus our energies, namely in human factors training for staff to help recognise and deal with error. Also, as in healthcare, we consider our passengers (patients) an integral part of our safety awareness system.

While I agree that patients are infinitely more complex than aeroplanes, the important point is that aeroplanes (patients) generally don’t cause accidents – it’s caused by human error due to the operator

Any issue brought to the attention of our cabin crew, such as unusual smells, sounds, ice on the wings or leaks from engines (both of which are much more easily seen by our passengers due to their better view of that area of the aeroplane), are brought immediately to the attention of the captain as part of our crew resource management information gathering system, ie, communication, leadership, situational awareness, leading to decision-making. We regard passengers as much more than passive consumers of our service.

Captain Niall Downey
FRCSI, Managing Director, Frameworkhealth, Ireland

Response

Capt Downey makes some excellent points and his thoughts are aligned with mine. It is certainly true that aeroplane safety relies to some extent on passengers alerting crew to potential problems, and in adopting a healthcare outcomes paradigm, similarly relying on patients for their expertise is crucial.

A difference is that the passengers on an aeroplane, except perhaps in the case of a mid-air emergency, do not rely on the crew to instruct them how to be successful passengers (after the initial safety instructions prior to takeoff), whereas achieving healthcare outcomes uniquely requires clinicians and patients to work very hard together across all aspects of care planning to achieve successful care implementation.

One of the reasons that 20-25% of elderly patients discharged from hospital with a diagnosis of congestive heart failure are readmitted within 30 days is because patients are not viewed as components of the healthcare system in a high-reliability model. Many clinicians have no real window on the challenges that patients face once discharged and back in their homes. Every preventable readmission is a failure of our system and a cause of physical, psychological and financial harm; the antithesis of a high-reliability system.

Clinicians and patients are both encumbered with many human factors liabilities and training or interventions for both are likely to serve good purpose. The processes of diagnosis, therapeutics and of care plan implementation present numerous human factors challenges. If the goal is preventing readmission then planning for that should begin at the time of admission with defining, and then modulating, the human factors that confound success.

DL Cohen
MD, FRCPCH, FAAP, International Medical Director, Datix (UK) Ltd. and Datix (USA) Inc. Dcohen@datix.co.uk

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