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We don’t talk anymore

01 May 2008

Mr Y, a 35-year-old marine engineer, was undergoing surgery in the posterior compartment of the thigh to treat a congenital vascular lesion. Mr O, consultant vascular surgeon, was carrying out the procedure. The lesion was closely related to the sciatic nerve and some of its branches, and Mr O was hoping to avoid damaging the sciatic bundle, if possible.

The anaesthetic was given by Dr A, consultant anaesthetist. During the induction phase Mr Y had suffered repeated generalised muscular spasms, so Dr A had given a muscle relaxant, to prevent intraoperative movement of the surgical field.

During the course of surgery, Mr O used tactile stimulation to attempt to determine whether a nerve which was likely to be compromised by his surgical approach was the sciatic nerve, or a branch of the peroneal nerve. Reassured by a lack of contraction of relevant muscle groups, he continued to operate under the impression that the structure about which he was concerned was not the sciatic nerve.

Unfortunately, in the context of neuromuscular blockade there was no rationale for this approach. It transpired that Mr Y suffered severe foot drop as a result of extensive damage to the sciatic nerve. Mr Y sued Mr O as a result of his injuries.

Expert opinion

The case hinged on whether Mr O had taken sufficient care in establishing the relevant anatomy during surgery. Dr A had documented in the anaesthetic record that he had given the muscle relaxant, and was adamant that he had told Mr O this fact. Mr O was insistent that Dr A had not informed him about the administration of the drug and thus had left him open to the error that he made.

During an investigation of events surrounding the case it became clear that there was a history of animosity between the two clinicians. There were unresolved investigations into allegations of bullying and harassment between Mr O and Dr A. In the context of how Mr Y suffered his injury, and the clinicians’ apparent failure to communicate, it was impossible to defend the case, which was settled for a moderate sum with liability shared equally between the two doctors.

Learning points

  • It is a professional obligation of a doctor to, as the GMC puts it “respect the skills and contributions of … colleagues and communicate effectively with colleagues within and outside the team.”
  • Effective communication between healthcare professionals is essential for safe patient care. In the context of an operating theatre, where there are anaesthetic factors that may have an impact on the surgical outcome (and vice versa), it is vital that this information is imparted.
  • Unresolved personal or professional disagreements between healthcare professionals who share responsibility for patients is potentially prejudicial to patient care. It is the responsibility of all who work in the clinical team, and those who manage them, to make sure that patients are protected from any adverse outcome that results from doctors not working properly together. The wellbeing of patients must always significantly outweigh the personal problems of doctors.
  • The rights and wrongs of any argument come second to their conduct. Both individuals could find themselves the subject of investigation by the regulatory authorities.

See the following recent paper on the issue of conflict in healthcare: Sorensen R, Iedema R, Redefining Accountability in Health Care: Managing the Plurality of Medical Interests. Health (London), 12(1):87–106 (2008).