Mr A, a 68-year-old pensioner, was diagnosed with bowel cancer after experiencing rectal bleeding and a change in bowel habit. He was investigated under the care of consultant surgeon Mr S, and scheduled for a local excision of a sigmoid mass.
Ms X, a year 5 specialty trainee working on Mr S’s team, performed the surgery. On opening Mr A’s abdomen, she found an unexpected mass adherent to the bladder, so called consultant Mr S to take over. Mr S proceeded to excise the mass. While assisting with the procedure, Ms X raised concerns that the mass they were working on was not the tumour they were initially aiming to remove, as it appeared anatomically too high. She pointed out that the preoperative investigations suggested the tumour was more distal. Mr S disagreed, continued to excise the mass, created a colorectal anastomosis and left Ms X to close.
Histology verified a sigmoid diverticular mass and evidence of cancerous cells in the donut of tissue removed from the rectum. The case was discussed with the whole team at MDT and Mr S instructed Ms X to advise the patient that further surgery was likely to be necessary, due to the microscopic evidence of retained tumour.
Mr A was readmitted a month later and underwent further surgery under the care of Mr S’s team (on this occasion, Ms X was not involved). While recovering on the surgical ward, Mr A was assaulted by another patient and sadly died of a subdural haematoma.
An inquest and subsequent trust investigation was held into Mr A’s death, during which Mr S was criticised for his oversight in excising the wrong mass during the earlier procedure and was referred to the Medical Council for investigation.
Ms X, who was not interviewed during either the inquest or trust investigation, raised the case with her educational supervisor and it was discussed as part of her appraisal.
Three years later, Ms X was contacted by the Medical Council and was informed they were investigating concerns that had been raised about her involvement in the care of Mr A. She contacted Medical Protection, who responded on her behalf, stating that Ms X was not the lead surgeon in the case and that she had raised concerns with Mr S during the procedure that he had excised the wrong mass. Mr S did not recall Ms X raising these concerns. As there were significant differences in the evidence offered by Ms X and Mr S, further investigation was anticipated.
Eighteen months later, a response was received. Case examiners at the Medical Council advised that the enquiry into Ms X could conclude without further action. Despite the unresolved differences in evidence given, they took into consideration the extensive reflections she had made regarding the case for her appraisal. Her career had continued to progress during the period of investigations, and she’d had no further adverse events.
‘Calling out’ a senior colleague is difficult and where there may be clinical uncertainty, it is easy to defer to a more senior colleague. However, whichever stage in training a doctor is at, there remains a duty of patient advocacy and Ms X correctly questioned the procedure they were undertaking on Mr A. Medical Protection’s factsheet on Raising Concerns and Whistleblowing looks at the issue in more depth – although this is a UK factsheet, the general principles apply anywhere in the world.
As the named consultant for the case, Mr S had overall responsibility for the care given, and made the treatment decision, which ultimately resulted in Mr A’s readmission and subsequent surgery. It was during this readmission that Mr A was assaulted, leading to his untimely death. In these circumstances, the law takes the view that, although the doctors could not have anticipated the assault, nor had any control over it, the fact remained that due to the inadequate primary procedure, the patient found himself back in hospital where he then suffered a fatal injury.
Written reflections by a doctor, along with clear and contemporaneous records, following an adverse event may influence the Medical Council case examiners’ decision whether or not a case can be closed without referral to a fitness to practise hearing.