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Cuts and bruises

01 January 2011

Mrs S was a 65-year old lady who had been suffering with stress incontinence and the discomfort of prolapse. She had a busy life looking after her three grandchildren and was finding her symptoms were interfering with this.

She was admitted by her gynaecologist, Mrs V, for a vaginal hysterectomy, anterior and posterior vaginal repair and a colpopexy.

The procedure appeared uneventful and Mrs V explained to Mrs S that the surgery should relieve her of her symptoms successfully. The next day, one of the junior surgical team noticed that Mrs S had a large bruise on her right buttock. This was discussed with the team and it was thought that this was caused due to her position on the operating table. Mrs S was reassured by this explanation and was discharged from hospital five days later.

Three days later, Mrs S began to feel unwell. She felt feverish and had rigors that frightened her. She also developed diarrhoea and some yellow vaginal discharge. She felt so unwell that she requested a home visit from Dr W, her GP. There was very minimal documentation in Dr W’s notes about this visit except that he started some antibiotics and that he had noticed a bruise extending from her buttock to her knee. In particular, there was no documentation of her vital signs such as temperature, pulse or blood pressure and no written evidence of an abdominal examination.

Over the next two weeks, Mrs S became increasingly concerned. She remained feverish and was finding it harder to walk because of pain in her right buttock and abdomen and swelling in her right leg. By the second week she was hardly able to walk at all and felt very unwell. She was visited at home by three different GPs from her practice. Each of the GPs noted the bruise that seemed to be extending down her leg but, again, did not document much else about her examination. The antibiotics were changed three times.

When the bruising and swelling in her leg continued to worsen, one of the GPs discussed her case with the on-call gynaecologist over the phone. The gynaecologist thought Mrs S may have a DVT and suggested she go to the emergency department (ED) rather than to the gynaecology ward. When Mrs S arrived, she went to the medical assessment unit. The medics assessed her, but the on-call gynaecologist did not. She spent two days in hospital and, although an ultrasound scan failed to show a DVT, she became increasingly unwell.

On the second day her temperature was spiking, her pulse was raised and her BP was running low. She was referred to the surgical ward, where she underwent an urgent CT scan, followed by a laparotomy. An extensive necrotising infection between the sacrum and rectum, extending into the right ischiorectal fossa, and multiple abscess tracks were found. Mrs S spent three months on the surgical ward undergoing extensive surgical treatment, including a loop sigmoid colostomy and recurrent debridement of the leg.

Mrs S was traumatised by her long stay in hospital, the discomfort of all the surgery and with having to come to terms with having a colostomy. She made a claim against Mrs V and the three GPs who visited her at home.

Expert opinion

Experts agreed that Mrs V did not take enough care, by performing a rectal examination, to ensure that the rectum had not been perforated by a suture during the posterior repair.

The GPs were criticised on several points. Firstly, it was felt that they had failed to consider a serious bacterial infection relating to Mrs S’s recent surgery. There was no documentation of her vital signs to assess the fever and severity of her condition.

Secondly, it was felt that they failed to adequately examine the bruising and swelling to the right buttock and leg. Lastly, it was felt that they had failed to arrange admission and investigation earlier. The on-call gynaecologist was also criticised for failing to assess the patient as requested and therefore delaying her care for 48 hours. The claim was settled for a substantial sum, divided between the hospital and the GPs.

Learning points

  • A diagnosis made by colleagues can always be challenged in the face of continuing symptoms. The three different GPs who saw Mrs S simply relied on each other’s opinion rather than seeking a new diagnosis.
  • The GPs were criticised not for failing to diagnose her, but for failing to realise how ill she was and organise a timely admission. There was no documentation of her vital signs that could have illustrated the severity of her illness.
  • Recent past medical history is likely to be relevant. It should be documented and considered.
  • When there are post-surgical complications, the standard of aftercare is extremely important.
  • This case highlights the importance of acting when a patient is deteriorating or failing to improve despite the working diagnosis and treatment.