Membership information 0800 225 677
Medicolegal advice 0800 982 766

Don't stick your neck out

01 November 2003

Ms J, a 30-year-old office worker, was referred to Mr O, a consultant general surgeon, by her GP. She had noticed a lump on the right side of her neck, which had been there for about a year. Mr O assessed her and found a hard, fixed lump in the right anterior triangle of the neck, considering it to be a lymph node in the right internal jugular chain.

At operation, through an oblique incision at the right angle of the jaw, Mr O found no evidence of an enlarged lymph node.He wondered if the mass was an exostosis of an upper cervical vertebra, ordering an x-ray to try and elucidate this. The x-rays were normal and a CT scan of the area revealed only bilateral small lymph nodes. Mr O arranged to reexplore the area at a later date.

When he did this, Mr O extended the previous incision and noted, ‘Despite normal x-ray appearances and CT result, this is an exostosis of bone. Excised with bone-nibbler. Bleeding controlled by pressure for 30 mins and Surgicel.’ Ms J developed a postoperative haematoma. The histology from the excised material showed normal bone and marrow with attached muscle and connective tissue.

Twelve days later Ms J was readmitted with severe pain on the right side of her face and was found to have a false aneurysm.

She was transferred to a specialist vascular surgeon at another hospital. An angiogram showed a large pseudo-aneurysm with an arterio-venous fistula between the right vertebral artery and internal jugular vein, at the level of C1 to C2.

Ms J subsequently developed a right lower motor neurone facial nerve palsy and underwent several operations to try and repair the fistula, successful on the third attempt. She suffered throbbing pain on the right side of her face, severe headaches, dizziness and depression. Her facial nerve palsy eventually resolved.

She started legal proceedings against Mr O alleging negligence for not carrying out sufficient investigations, not referring for appropriate specialist advice, not recognising the injury to the vertebral artery and undertaking the operation without good reason.

Expert opinion

Expert vascular-surgical advice was that Mr O’s care fell below the reasonable standard expected of a general surgeon. Mr O was criticised for going ahead with the surgery with the information he had, and for not requesting a specialist opinion in the light of uncertainty about the diagnosis.

Neurosurgical advice concurred and noted, ‘an approach to a deep upper cervical lesion would be best done using micro-surgical techniques, preferably though not necessarily by a neurosurgeon. An otolaryngologist or a specialist in head and neck surgery would also be comfortable operating in this anatomical area.’ We settled the claim for a large sum.

Learning points

The General Medical Council advises, ‘In providing care you must:

  • Recognise and work within the limits of your professional competence;
  • Be willing to consult colleagues; and
  • Be competent when making diagnoses and when giving or arranging treatment.’

Particulars of Negligence included

  • Failing to carry out sufficient diagnostic tests.
  • After the procedure, failing to refer to a surgeon specialised in this type of surgery.
  • Undertaking a second operation when there was no evidence of malignancy.
  • Failing to recognise that during this procedure an injury had been done, causing an arterio-venous fistula
  • Failure to diagnose the fistula postoperatively.