Baby R presented at 18 months of age with a fit. He seemed otherwise healthy, but a CT scan was performed, which showed a Sylvian fissure arachnoid cyst with a shift of midline structures. After careful discussion with the parents, it was agreed that the baby would have a craniotomy and fenestration of the cyst into the subarachnoid space.
Following this procedure, carried out by consultant neurosurgeon Dr F, Baby R began to do well and had no further fits. A few months later he was re-referred by the GP because he had become increasingly lethargic and off his food. A CT scan demonstrated that the cyst had recurred and was now bigger than it had been originally.
Dr F again discussed with the parents the various options and their potential complications; these were documented in a letter back to the GP. In the end, it was agreed that Dr F would take Baby R back to theatre and perform a cysto-peritoneal shunt.
During the insertion of the shunt, fresh blood began to appear in the proximal catheter. Dr F flushed the tubing with sterile water until the cerebro-spinal fluid became clear. After waiting a short period, more blood began to appear in the tubing and Dr F decided to open the dura to find the bleeding point. After reopening the craniotomy, Dr F found that the shunt had penetrated the brain tissue, causing bleeding from a vein on the cortical surface. The bleeding was stopped and the shunt procedure completed.
Baby R was taken from the operating theatre for a CT scan, which showed a slight brain contusion at the site of the cortical puncture and shrinkage of the cyst. He was then extubated and taken to the paediatric intensive care unit where he was closely watched by Dr F and the paediatric intensive care consultant. Dr F informed the parents about what had happened in the operating theatre but said that he felt everything would now be fine.
For the next couple of hours, there were entries in the clinical notes every few minutes and initially all was well. Unfortunately, four hours following the operation, Baby R developed a dilated pupil and a bradycardia. He was taken back for a CT. The scan showed a large haematoma had developed at the site of the cortical puncture and the baby was taken immediately to theatre for drainage of the clot. In spite of the surgery, Baby R was left with a severe neurological impairment.
A claim was made against Dr F by Baby R’s family, alleging bad management both during and after the operation. Experts reviewed all the notes and concluded that the management had been careful and appropriate and Dr F wasn’t to be blamed. In particular, the consent process was well documented and it was clear that the parents knew about the possibility of bleeding and the potential consequent neurologic damage. The case was successfully defended.
- In particularly complicated cases, the more detailed the medical records, the more robust the defence. As this case demonstrates, documenting the time of the notation can be very important. It was clear from the medical records that Baby R had been observed very closely in the hours following his surgery and therefore the postoperative care could not be criticised.
- Complications are unfortunate but do happen and, in some cases, can have terrible and lifelong effects on patients. The medical records are clearly vital in documenting the consent process, which is at the heart of patient-centred medical care.