The missing belly button

November 2004

Miss S was born with a very large umbilical hernia. Her consultant paediatrician remarked that it was the largest he had ever seen, and asked a surgical colleague, Mr A, to advise. Mr A told Miss S’s mother that the hernia needed surgery, as it would be unlikely to reduce spontaneously. Miss S’s parents gave their consent for the operation.

The surgery was carried out as a day case when Miss S was two months old. There appeared to be no problems at the time. Mr A excised the large pouch of redundant skin which had contained the hernia.

When the dressings were removed Miss S’s parents were not happy to find that their daughter no longer had a navel. They went back to see Mr A and complained. He sent Miss S to a plastic surgeon who fashioned a new umbilicus.

The parents sued, alleging that they hadn’t been warned that this could happen. They claimed that the excision of the umbilicus was unwise and contrary to proper surgical procedure, and that Miss S’s age meant that the surgery was not necessary in any case.

Mr A wondered if a haematoma had lifted the umbilicus from its underlying blood supply and caused it to disappear. He couldn’t be certain that he hadn’t removed it when excising the redundant skin pouch. As to the question of premature surgery – for a condition which is normally left until a child is a few years old before deciding that it will not spontaneously reduce – Mr A could give no concrete justification other than the size of the hernia.

In terms of consent for the procedure, Mr A hadn’t documented any preoperative discussion of the risks of surgery with Miss S’s parents. The consent form that should have been in the notes was missing. Mr A agreed that the case should not go to court and so we settled on his behalf for a sum equivalent to nearly £52,000.

 

Learning points

  • Consent – This case occurred in an Irish hospital. The test for informed consent in Ireland follows the ‘prudent patient’ principle. That is, patients – or their legal guardians in the case of minors – must be told of any possible complications that a normally prudent person would wish to know about.
    Deformation of the natural appearance of a newborn baby would fall into this category, even if the particular lesion may seem of no major significance to a practitioner.
  • Integrity of records – The missing details of the consent process reduced the chance of defending this case. Training staff about the importance of maintaining the integrity of the clinical record, and redesigning case records so that the loss of important documents is less likely, are important issues for clinical-governance leads/managers to consider.
  • Indications for surgery – If you are managing a condition that is not usually treated surgically, take care to document at the time your thoughts about the need for surgery. If a claim occurs later on, this will remind you of why you took a particular course of action, and could help defend it. Make sure that you are operating only where non-surgical therapies are inappropriate or have been tried unsuccessfully.

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