Minor operation – major problem

Being relatively experienced at his level, he was concerned with the appropriateness of the prescribed treatment, but felt uncomfortable contradicting his senior

Mrs W, a 25-year-old secretary, was referred by her GP to a local general surgeon, Mr D, with troublesome warts on the middle finger of her dominant hand. On the day of the consultation, there were pressures in the consultant’s outpatient clinic as one of his juniors had unexpectedly gone off sick. In the event, he did not make any record of the consultation, but completed a booking form for Mrs W to have “diathermy of warts” on the minor surgery list delegated to junior doctor Dr Q.

On the day of the procedure, Dr Q was unsupervised for this list. He searched the notes for some advice or indications by way of an entry or letter to the GP, but could find none. Being relatively experienced at his level, he was concerned with the appropriateness of the prescribed treatment, but felt uncomfortable contradicting his senior so, after asking the patient to sign the form of consent, proceeded nevertheless.

Some days later, the patient returned with a black sloughy wound over a 1.5cm area on the dorsum of the PIP joint, which went on to become infected despite the prescription of antibiotics. Another member of the team subsequently saw Mrs W and realised that the developing wound was exposing the extensor tendons and asked an orthopaedic colleague if she would perform a skin graft to get the wound healed. This was done under local anaesthetic, using skin harvested from the patient’s chest wall. Unfortunately, the graft didn’t “take” well and the finger wound proceeded to heal slowly by scar formation.

There is no such thing as a “minor operation”

Mrs W went on to need several months’ physiotherapy to her hand, but was left with very significant stiffness in the finger. She also unfortunately developed a nasty scar on her chest at the site of skin graft harvest. After returning to her job she found herself only able to type at much reduced levels of efficiency and lost her job in a subsequent staff review at her firm. She became very depressed. Mrs W made a claim against both Mr D and Dr Q. Expert opinion was sought during the process and it was agreed that there was neither adequate informed consent nor appropriate primary treatment for the condition. The claim was settled for a moderate sum.

Learning points

• Clinical misfortunes are extremely difficult to defend without good record-keeping

  There is no such thing as a “minor operation”. As this case demonstrates, all procedures have the potential to produce complications, which may escalate. Sometimes the effect of such complications can be magnified, particularly in the area of the human hand, which a patient’s livelihood could depend on.
• When you delegate care or treatment you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved. Although you will not be accountable for the decisions and actions of those to whom you delegate, you will still be responsible for the overall management of the patient, and accountable for your decision to delegate.
• If there are complications requiring specialist input, then that expertise should be sought. In this case, the patient had a skin graft harvested from her chest wall and ended up with a large scar. It is almost always inappropriate to harvest skin grafts from the chest wall and a plastic surgeon’s opinion would most likely have prevented this.
• Clinical misfortunes are extremely difficult to defend without good record-keeping.
• In today’s increasingly cost-conscious and frenetic health service, there are more and more pressures on doctors to take short cuts and minimise costs. The experienced clinician needs to know when these pressures should be resisted to avoid a fall in standards of good care.
• Referrals to hospital specialists should be as clinically appropriate as possible. Where hospital specialists receive what appear to be referrals outside their sphere of expertise, they should triage them accordingly.