Mrs S, a 77-year-old woman whose past medical history consisted of a previous hysterectomy for benign fibroid disease, presented to her GP with a history of intermittent hematuria. Her GP recognised the potential seriousness of this symptom and made an urgent referral to a consultant urologist, Mr F.
Mr F arranged an IVU followed by a CT scan, which suggested a tumour in the left distal ureter. Mrs S was advised this was highly suggestive of carcinoma and required surgical removal. However, Mr F arranged a biopsy of this mass via a ureteroscopy which was reported as inconclusive, containing insufficient material to make a definitive diagnosis; repeat biopsy was recommended by histology. There was nothing documented within the records to show that the implications of the same were discussed with Mrs S.
Mr F proceeded with left radical nephroureterectomy; a decision supported by the local multidisciplinary meeting. During surgery, Mrs S was found to have a 5cm tumour and a sigmoid colon adherent to the pelvic side wall due to multiple adhesions from her prior surgery. The histology of the nephro-ureterectomy specimen showed no evidence of malignancy with endometriosis in the ureteral wall and lumen. This was communicated to Mrs S who felt that she had been misinformed as to the purpose of the surgery (as she had never had cancer).
Unfortunately, the postoperative recovery was complicated by a colo-vaginal fistula, and Mrs S had to go back to theatre for an emergency laparotomy and Hartmann’s procedure. After this, Mrs S developed an incisional hernia, which was repaired along with a reversal of the Hartmann’s one year later.
Mrs S indicated an intention to bring a claim stating that she had undergone surgery based on a false premise. She alleged that she would have requested repeat biopsy (as recommended on the biopsy findings within the records), which would have come back negative for malignancy and thus she would never have agreed to surgery.
The expert opinion on the case indicated that it was reasonable for Mr F to perform an initial ureteral biopsy, but that it must be recognised (and should have been made clear to the patient) that often such biopsies are not diagnostic; hence, repeating the biopsy may not have revealed any further information.
The expert was also of the view that the MDT decision to proceed to radical nephro-ureterectomy was justifiable, even if the true diagnosis of endometriosis had been made. Due to the location and size of the mass radical surgery would still have been warranted.
MPS set out their expert evidence and indicated they would defend Mr F in the event a formal claim was commenced. The case was not subsequently pursued.
- Communication and documentation is vital. Had the specific purpose and limitations of the biopsy been explained clearly to Mrs S at the outset, and the options for further management discussed thoroughly, she might not have brought the claim. As with many claims, the claimant did not sue based on the outcome of the surgery but rather because of lack of communication and correct information.1 All medical practitioners must make time to ensure their patients fully understand all aspects of their management.
- B-Lynch C, Coker A, Dua JA, A clinical analysis of 500 medico-legal claims evaluating the causes and assessing the potential benefit of alternative dispute resolution, Br J Obstet Gynaecol 103(12):1236-42 (1996)