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Tardy surgical intervention

01 August 2003

Mr W, a diabetic gentleman in his sixties, saw his GP because of abdominal pain and vomiting. His doctor suspected appendicitis and made an urgent referral to his local hospital. He was seen there by Mr F, a locum consultant. No notes were kept of the initial consultation.

Mr F later stated that he found Mr W to be jaundiced, with tenderness in the right upper and lower quadrants. Mr F suspected acute cholestatic disease, ordering an urgent ultrasound scan. He ordered a sliding-scale glucose/insulin infusion and prescribed IV cefuroxime, metronidazole and analgesia.

Mr W was pyrexial and hypotensive on admission. Initial investigations showed normal U&Es, an elevated bilirubin of 122 µmol/l (NR 4–17), glucose 11 mmol/l and a white-cell count (WCC) of 5 x 109/l (83% neutrophils, NR 4–11).

The scan showed no evidence of biliary obstruction. There were dilated loops of small bowel, also seen on a plain abdominal x-ray. Mr F was consulted about these findings and advised continuing conservative management.

The next day, Mr W was consistently pyrexial with generalised abdominal tenderness and absent bowel sounds. A possible mass was palpated in the right lower quadrant, but not investigated further. He was started on intravenous erythromycin. By the third day his urea had risen to 20 mmol/l, bilirubin falling to 37. His WCC was now 7.3 (87% neutrophils).

The notes say that on the fifth day Mr W was ‘doing fine’. His WCC climbed to 12.6, and his fever persisted. On day six, WCC was 20.5. By day seven, Mr W was recorded as suffering from severe abdominal pain, but the examination records a soft abdomen with no mass. The WCC had risen to 23.3 (89% neutrophils).

Over the next five days there is no record of Mr W’s temperature. For two of the days there is no record of clinical review, but the nursing notes do indicate visits by the surgical team. Mr B, consultant surgeon, returned from leave and repeated the ultrasound scan, which showed possible intra-abdominal abscesses. He performed a rigid sigmoidoscopy but found nothing abnormal.

Eleven days after admission, Mr B decided to take Mr W to theatre where he carried out a laparotomy.

He found intra-abdominal pus, a walled-off right-sided abscess and a thickened, hard appendix, which he removed.

Unfortunately, Mr W suffered septicaemic shock and multi-organ failure in the postoperative period. He died 22 days after his admission. His family sued, alleging clinical negligence by Mr F and Mr B.

Expert opinion

We consulted a surgical expert who accepted that the jaundice was atypical and confusing, but was critical of the decision not to proceed to laparotomy, once imaging had excluded biliary obstruction.

The expert commented, ‘His temperature persisted in spite of antibiotics and the WCC steadily rose … a mass was felt that should have been more thoroughly investigated. All signs indicated an abscess formation, which should have been explored at an earlier date before its rupture … had surgical exploration been undertaken at an earlier time, his death in all probability would have been prevented.’

We settled the case for a substantial sum.

Learning points

The decision-making processes of the team in question appear to have been seriously impaired, leading to an avoidable death, caused by unnecessarily delayed surgery.

The website of The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) contains useful information for surgical teams not wishing to fall prey to the same errors. Its document ‘Functioning as a team?’ can be viewed at www.ncepod.org.uk. The section ‘Decision-Making and Surgery’ is particularly pertinent to this case.

This case also features in UK Casebook 2004 (1), February, in The acute abdomen.