MPS medicolegal adviser Dr Gordon McDavid comments on the case
This tragic case highlights the risks involved in all medical procedures – even those carried out relatively frequently. It offers a stark reminder of how challenging medicine can be – diagnostic uncertainty often requires doctors to consider the most likely and most significant diagnosis, which may later turn out to be incorrect; in this case the presumed PE.
Fortunately, chest drain complications are rare. However, it is important that care is taken before any procedure to ensure the patient has provided their informed consent and that conditions are as safe as possible. If there is any doubt, the procedure should be postponed until you have investigated further; provided it is clinically appropriate to do so.
In this case, the patient required a chest drain as an emergency which meant that the usual careful preprocedure consideration could not be undertaken. A doctor would be expected to act in a patient’s best interests at all times. Action should be taken to save their life or prevent serious deterioration in a patient’s condition.
When an adverse event occurs, investigations will follow. It is vital that meticulous notes are made contemporaneously. This will assist the doctor by explaining what happened at the time and offering justification for the steps taken.
The surgeon who carried out the chest drain insertion will undoubtedly feel terrible about what happened. It is important to remember that mistakes do happen. The most important step following any adverse event is to ensure the patient is looked after.
When suitable, the patient should be informed openly about what happened – in this case, as the patient did not recover, that explanation should be offered to the family in an honest and considerate way.
An adverse event should be formally reported so that it can be thoroughly investigated to consider if any steps should be taken to prevent recurrence. The individuals involved should participate in that process fully, but see it as a learning exercise, rather than a process to attribute blame.
Those involved should also undertake personal reflection no matter how senior they are. Discussion with colleagues is also helpful, to consider what they would have done in similar circumstances. Any adverse event should be discussed at the doctor’s appraisal too. In conjunction with the hospital’s internal review, there may be other processes that arise out of an adverse event.
Where a patient has died, it is likely the case will be considered by the coroner or procurator fiscal who may call an inquest or fatal accident inquiry. To assist in such investigations, a professional report will be sought from those involved. Therefore it is useful for a doctor to compose a draft report as soon as possible after an adverse event.
Remember that MPS remains on hand for members to contact for advice. Offering more than just defence, we can assist in annotating a professional report and offer guidance, advice and support through the multiple processes that may arise out of a clinical incident.
When things go wrong, a complaint from the family may follow – either directly to the hospital or through other channels, such as the GMC. They may also attempt to claim for damages. You can contact MPS for advice if such developments transpire.
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