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Strong record-keeping – strong defence

19 July 2018
By Mr Sam Dresner, general surgeon

Ms Q, 58 years old, consulted Dr G, a gastroenterologist, with a history of dyspepsia, early satiety and altered bowel habit. Clinical examination, including digital rectal examination, was recorded as normal.

Dr G requested a full set of routine bloods and a chest x-ray (Ms Q had a long history of asthma), all of which were normal. Ms Q was advised that an upper gastrointestinal endoscopy and colonoscopy were required to further investigate the cause of her symptoms. Dr G documented that he had discussed the nature of the investigations, the possible need to take biopsies or remove polyps for histopathological examination and the risks involved. He provided standard hospital information booklets about the endoscopic procedures and obtained written consent from Ms Q. Specifically, he advised her that there was a very small risk of perforation (of the order of less than 0.01% for an upper gastrointestinal endoscopy and 0.1-0.5% for a colonoscopy), which might require emergency surgery.

Dr G provided Ms Q with bowel preparation and scheduled her appointment for a bidirectional endoscopy a few days later. When she attended for the investigations, Dr G reviewed her again in the presence of an endoscopy nurse. He went over the procedures once more and the risks involved, and obtained further written confirmation of her consent.

The hospital records indicate that the patient entered the endoscopy room at 12pm and was provided with conscious sedation using intravenous midazolam and fentanyl. Her blood pressure was recorded as 130/60, oxygen was supplied via nasal cannula and her saturations noted as >98% throughout the procedure. The initial upper gastrointestinal endoscopy demonstrated some mild antral gastritis but no other abnormalities. A helicobacter pylori test was negative.

Antral biopsies were taken, which later confirmed acute-on-chronic gastritis and intestinal metaplasia. Attention then turned to the colonoscopy. Dr G recorded that the colonoscope was inserted up to 25cm, where extensive diverticular disease was evident. Dr G encountered difficulty in negotiating this segment of the colon, noting diminished insufflation and that Ms Q was experiencing pain. A colonic perforation was suspected, and the procedure was therefore immediately abandoned.

Dr G noted that Ms Q’s abdomen was distended, with lower abdominal tenderness but no peritonism. He prescribed broad spectrum intravenous antibiotics, intravenous fluids and more opiate analgesia, and advised that she should be kept ‘nil by mouth’. Ms Q remained stable and was transferred directly to the radiology department for an urgent CT scan of the abdomen and pelvis, and afterwards was moved to a ward at 1.05pm.

Dr G attended Ms Q at 1.40pm and informed her and her relatives that a perforation of the colon had been identified on the CT scan, with extensive retroperitoneal gas but also some possible intraperitoneal free gas and fluid. By this stage Ms Q’s abdomen had become more distended, her pain was worse and she had a tachycardia >100bpm. Dr G advised that in view of her clinical deterioration and the CT findings, surgery would probably be required. After discussion with Ms Q and her relatives, he arranged transfer to a nearby emergency hospital facility. 

Dr G contacted the on-call surgical team at the nearby hospital, prepared a referral letter and escorted the patient during her transfer, briefing the receiving staff on her condition upon arrival. Emergency surgery was performed later that day with resection of the perforated diverticular segment and primary anastomosis. Dr G contacted the surgeon the following morning, who confirmed that the prompt action had minimised the contamination seen in the abdominal cavity at the time of surgery, allowing him to perform a primary anastomosis. Dr G visited the patient several times during her admission and subsequently saw her in his clinic for review after discharge, noting that she had made a full recovery.

Three years later just before the end of the limitation period for bringing a claim, Ms Q decided to pursue a claim against Dr G.

Expert opinion
It was clear from the detailed documentation that Dr G provided to his Medical Protection legal team that he had acted entirely appropriately in response to a well-recognised but rare complication. Ms Q had been clearly warned about and understood the risks prior to the procedure. As a result, expert advice for Medical Protection concluded that the patient’s solicitors were unlikely to pursue their claim and, indeed, the case was subsequently dropped.

However, Ms Q went on to complain about Dr G to his Medical Council. Medical Protection again assisted Dr G by providing further reassurance and advice, confirming that their independent expert opinion felt his actions had been entirely appropriate. They helped him compile an appropriate response to the investigation, which demonstrated reflection and insight but robustly defended his communication with the patient and the subsequent handling of this well recognised complication. The complaint was dismissed without further action.

Learning points
  • Accurate and clear documentation, which often may need to be relied upon years after the event, are the cornerstone of any medicolegal defence. In this case, there was a thorough process of consent, recording the risks of the colonoscopy and the potential consequences of any complications. When it became apparent that a perforation had occurred, Dr Q was able to rely on his detailed notes, which confirmed his prompt and appropriate actions and his clear communication with the patient and her relatives. 

  • The development of a complication is not necessarily evidence of negligence, provided the patient has been warned of the risks, the procedure has been carried out to an acceptable standard and all reasonable steps have been taken to minimise the effects of the complication. In this case Dr Q’s prompt and appropriate actions may have prevented further contamination of the abdomen and the severity of sepsis. Although ultimately this did not prevent a legal claim it helped contribute to a robust defence. 

  • This case also highlights the necessity to be open and honest when complications develop. All healthcare professionals have a professional responsibility to be honest with a patient when things go wrong: this was exemplified by Dr G’s prompt and clearly documented communication with Ms Q and her relatives. This was not a medical mistake but a recognised complication about which Ms Q had been warned. Although Dr G’s open and honest approach did not prevent the complaint to his Medical Council, it helped contribute to its dismissal as he was able to demonstrate that he had carried out professional duties promptly and appropriately.