Paediatric brain injury

A three-year-old child, BC, was admitted to hospital for investigation following an epileptic fit. A CT scan demonstrated a left-sided Sylvian fissure arachnoid cyst with bulging of the overlying temporal bone (but no midline shift).

BC underwent cyst drainage with insertion of a shunt under the care of Mr S, a consultant paediatric neurosurgeon, but it was complicated by an intracranial bleed. Intraoperative exploration revealed that there had been an injury to the temporal lobe that was likely to have been associated with the insertion of the ventricular catheter (which was not inserted entirely under direct vision). The haemorrhage was under control when the operation was concluded.

Following the surgery, BC was transferred to the paediatric ward as a high care patient. Mr S left the hospital having handed over care to Dr K, a consultant paediatrician, and Mr P, a consultant neurosurgeon. Mr S explained that BC had had an intraoperative bleed, that a clotting screen should be checked (to exclude an underlying bleeding disorder) and that regular neurological observations should be undertaken. Unfortunately the handover discussions were not documented in the records.

BC remained stable until early evening when Dr K was asked by the nursing staff to review her because she had started to vomit and had developed a dilated left pupil. A repeat scan demonstrated a haematoma in the Sylvian fissure with consequent displacement of the shunt, impingement of both the temporal and parietal lobes, together with a midline shift. Mr P was called and immediately returned BC to theatre to evacuate the haematoma.

Unfortunately BC sustained a neurological injury, which left her with a right-sided hemiparesis, cognitive difficulties and ongoing epilepsy.

The parents pursued a claim alleging: 

• the original procedure was not indicated (and that non-surgical approaches were not considered);
• the shunt was inserted negligently, which led to the bleeding and associated brain injury;
• the bleeding was not adequately controlled in the context of the first procedure; and
• BC should have been transferred to a paediatric intensive care facility so that her neurological condition could have been monitored intensively.

Expert opinion

Medical Protection sought an expert opinion from a consultant paediatric neurosurgeon, who was not critical of Mr S’ decision to drain the cyst and insert a shunt. However, concerns were raised in relation to the operative technique which, the expert said, was not according to standard practice.

The expert indicated that the preferred approach would be to insert the ventricular catheter under direct vision and postulated that there may have been damage to one of the branches of the middle cerebral artery. The expert was not critical of the decision to transfer BC to a paediatric ward (on the basis that she did not require ventilation and that the monitoring facilities on the ward were appropriate) but was concerned about the lack of written and verbal instructions (particularly directed towards the nursing staff) relating to the postoperative care and neurological observations. In addition, the expert was of the opinion Mr S should have reviewed BC on the ward given that he had performed a surgical procedure on her that had been complicated by bleeding.

In light of the vulnerabilities highlighted by the expert, the claim was resolved by way of a negotiated settlement.

Learning points

• The allegations were wide-ranging and although the expert was supportive of some aspects of Mr S’ involvement in BC’s care, the concerns in relation to the operative technique and handover meant that there was no realistic prospect of defending the case successfully.
• The case emphasises the importance of communication and record keeping, particularly with reference to providing clear verbal and written handover to all relevant staff.
• It may be entirely appropriate to leave the care of a patient in the hands of colleagues at the end of a shift but it would have assisted Mr S’s defence if he had reviewed BC on the ward postoperatively in light of the fact that the neurosurgical procedure had been complicated by bleeding.

Further reading