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Too keen to close

01 September 2007

Mr P was a 17-year-old student who attended the Minor Injuries Unit at his local A&E department after a fight. He walked in and sat in the waiting area with a friend. The triage nurse offered him some analgesia but he refused it.

Mr P was triaged as a minor injury so the nurse did not carry out any observations on him.

Dr G, an F2 doctor, saw Mr P, who told her that he had been involved in a fight and sustained a stab wound in his abdomen about two hours earlier. Mr P described the weapon as a kitchen knife and he said that he felt it going quite deep.

There was not much blood on his T-shirt, but he said that he had changed his clothes at home to avoid alarming his mother.

Dr G examined Mr P and found a 1.5cm wound in the right upper quadrant with no active bleeding. The rest of the abdomen was soft and non-tender.

Dr G had never managed a patient with a knife wound before so she went to get some advice from a senior colleague in the main A&E department. The department was extremely busy and the senior doctors were all in the resuscitation room with two big trauma cases.

The floor manager approached Dr G to ask her about her plans to deal with this patient. Mr P only had 40 minutes before he breached the four-hour target. Dr G told her that she was about to treat Mr P.

Dr G explored the wound under local anaesthetic. She didn’t think that the wound was deep so she sutured it with two non-absorbable stitches and sent the patient home.

Next morning Mr P’s mother found him unresponsive in his bed. The paramedics diagnosed cardiac arrest and started resuscitation. Unfortunately, Mr P was pronounced dead on arrival at hospital. The autopsy revealed a laceration to the liver with extensive intra-abdominal haemorrhage.

The case against Dr G was settled by the hospital for a moderate sum.

Learning points

  • It is always good practice to ask a senior colleague for help if you are unsure about the management of a patient. Do not allow any non-clinical pressure to interfere with your clinical decision. Dr G should have waited for one of her senior colleagues to help her with an unfamiliar scenario. Instead, she allowed other considerations to force her into treatment that was beyond her expertise.
  • A patient who walks into a Minor Injuries Unit might still have a serious illness or injury. Always consider the history and examination of a patient on their own merits, regardless of the way they arrive or the place where you see them. A patient with a stab wound in the abdomen or chest always needs to be closely observed and it is important to monitor blood pressure and heart rate.
  • Stab wounds can be deceiving because it is difficult to assess the trajectory and depth of the wound. They will need surgical exploration where appropriate.