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Corporate indemnity: Are you protected?

Company directors and non-medical staff and institutions are sometimes named in clinical negligence claims, and the consequences of failing to arrange suitable indemnity protection can be serious. Gareth Gillespie looks at two recent MPS cases

For clinicians in the Caribbean, the sense of awareness surrounding medicolegal pitfalls in their practice is generally high – however, for administrators of hospitals, clinics and general practices, this awareness has not always been at the same level. The same standards and duty of care are expected of the institution as of the clinicians. Adequate protocols, procedures and regulations should be in place to prevent allegations of negligence.

Medical indemnity from organisations like MPS is available for doctors but what happens when the search for compensation extends beyond the limit of the individual practitioner? Who covers errors attributable to ancillary staff, the directors or the institution? How does a clinic administrator respond to alleged negligence when he/she may have had no training in medicine or the legal aspects of medicine?

Standard insurance policies usually cover such mishaps occurring from events related to the physical premises – for example, a slip on a wet floor where there is no appropriate signage – but they don’t extend to the operation of the practice itself or any act or omission that relate to clinical negligence. Shouldn’t the administration be afforded similar levels of comfort as the practitioners? The concept of corporate indemnity could fill such a need.

Dr Nancy Boodhoo, MPS Head of Operations (Caribbean and Bermuda), says: “MPS has seen an increase in the corporate membership in the Caribbean, in terms of hospitals, small institutions and clinics.

“There has also been a steady increase in the types of cases where institutions or companies have been named defendants and corporate membership has been necessary or useful. Although the company or institution can often be taken out of the action, there can be considerable cost in legal fees in achieving this.

“MPS assists corporate members in establishing a robust and effective adverse incident reporting system. This provides very useful information for the institution in establishing where the shortfalls lie and where there are repeated problems. By efficient and careful analysis of this information, institutions with limited funding can direct their expenditure to areas where there will be maximum benefit. This might be simple systems such as prioritising where a limited number of available bed rails are used – directing them to where there have been the greatest number of falls or using arm tags for patients with drug allergies.

“As medical practice in the region continues to grow – in the form of group practices, small institutions and specialist centres – corporate indemnity is more important than ever and should be given due consideration.”

Case 1

Mrs T was a 30-year-old shop assistant who gave birth to a baby girl via a normal vaginal delivery at 39 weeks gestation. During the delivery, Mrs T required an episiotomy, which was performed and sutured by nurse Miss J. Mrs T’s antenatal care had been uncomplicated.

Two weeks later, Mrs T presented to Dr D, consultant in obstetrics and gynaecology. She complained of severe pelvic pain and difficulty walking. On examination, Dr D noted dehiscence of the left mediolateral aspect of the episiotomy and bacterial vaginitis. Mrs T was prescribed a course of oral antibiotics and was instructed to continue sitz baths; a follow-up examination showed resolution of the vaginal infection but the dehiscence persisted. The edges were reapproximated and stitched. Mrs T further noticed another dehiscence at the proximal third aspect of the episiotomy, which was managed conservatively with sitz baths.

A further follow-up examination revealed complete closure of the episiotomy incision but a small painful nodule on the left labia minora. Dr D cauterised the nodule and Mrs T reported that she was able to walk without difficulty.

Two months later, Mrs T made a claim against the hospital for what she alleged was negligent treatment by Miss J. Mrs T claimed that Miss J’s execution of the episiotomy was negligent and the source of the various complications that arose afterwards. Mrs T further claimed post-traumatic stress disorder – for which she had to pay for psychotherapy – loss of bonding with her baby, temporary disability and loss of earnings.

MPS resolved to defend the case to trial. At court, the MPS legal team applied to have the claim struck out because of the expiration of the sixmonth limitation period. The judge accepted the application and MPS was able to recover its costs from the claimant.

Case 2

Miss R was admitted to hospital with a history of vomiting; she also had a previous history of diabetes and hypertension. On admission she was diagnosed with uncontrolled diabetes and hypertension, and ketoacidosis was ruled out. She was treated with IV fluids and other medication as her diagnosis warranted. Miss R was noted to have an IV infusion in her right arm after a few days but it is unclear how long this was in place.

Two days later, Miss R visited the Emergency Department (ED), complaining of pain and swelling in her right forearm, which reportedly occurred after she was administered an IV infusion during her previous admission. She was treated with IV fluids, insulin and a Voltaren injection for the pain. She also had an x-ray of the affected arm and was kept for observation.

Miss R was referred to the Internal Medicine Department, where Dr V diagnosed cellulitis of the right forearm and hand. Miss R was prescribed Voltaren for the pain, antibiotics, aspirin, Lipitor, Zestril, sliding scale insulin and vitamin C. She was then transferred to the Female Medical Unit for further management.

A day later, Miss R’s condition was recorded as stable but she continued to complain of pain to the affected arm, which remained swollen. Her previously prescribed insulin dosage increased almost daily due to persistently elevated blood sugars. However, a few days later, Dr V recorded that Miss R was not receiving her correct dose of insulin. Some discrepancies were observed between the dosages of insulin ordered and the amount administered.

Two days later, Miss R was seen by the surgical team. Her right arm was described as oedematous and tender up to the forearm and erythematous. Miss R was unable to grasp with her fingers. She was again diagnosed with cellulitis of the right forearm, and an incision and drainage of the affected arm were performed, with serous fluid aspirated. Fortum and gentamycin were added to Miss R’s previous medication.

The following day there was a slight improvement in the swollen arm but Miss R continued to complain of pain. She was seen by Dr K, a consultant in general surgery. A fasciotomy was carried out after a review of the affected arm revealed unhealthy necrosed tissue, which appeared to be due to diabetic ischaemic necrosis of the right forearm. Radial pulse was not felt and there were no active finger movements. Following the fasciotomy, Miss R’s blood sugar remained elevated.

Miss R was then reviewed by Dr M, orthopaedic consultant, who noted partial necrosis of the right forearm and no sensation or pulsation in the affected arm. The prescribed treatment continued and Miss R was monitored by doctors from the internal medicine and surgery departments.

Miss R’s blood glucose remained uncontrolled. An arterial Doppler examination was performed, followed by an exploration of the brachio-radial artery. There were further surgical interventions carried out on Miss R’s arm over the next month: three debridements and a secondary suturing of the forearm.

The general condition of Miss R’s affected arm continued to deteriorate. She had regular dressing changes and prescribed medication inclusive of insulin and antibiotics continued. Her blood glucose levels continued to fluctuate. The condition of the wound also fluctuated – between a red and healthy appearance to sloughy. Miss R then developed pseudomonas infection to the wound, which was treated with the required antibiotics. The wound healed gradually and glucose levels finally became controlled. She was discharged from surgery and her treatment continued in internal medicine.

Following satisfactory control of Miss R’s blood glucose levels and the healing of the wound, she was discharged from hospital, after which she received physiotherapy as an outpatient.

Miss R lodged a claim against the hospital for various aspects of her treatment. She alleged that her infections and subsequent surgical interventions could have been avoided with more timely administration of her antibiotics. Miss R also claimed that incorrect dosages of insulin worsened her infection, and that there were delays in her admission to internal medicine and the surgical department.

As with the previous case, there was a delay in the claim being served – therefore, the MPS legal team applied to have the claim struck out. This application was successful.

With thanks to Dr Jonathan Bernstein for his assistance with this article.

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