Dr Marika Davies: The case we’re going to look at now emphasises just how important strong record keeping is – and continues to be - even many years after a patient has been treated. A patient went to see her gastroenterologist about dyspepsia, early satiety and altered bowel movement.
Clinical examination and blood tests were recorded as normal. The patient was advised that an upper gastrointestinal endoscopy and colonoscopy were required. The consultant also explained the nature of the investigation to her, including the very small risk of perforation that might require emergency surgery.
He gave her leaflets about the procedures and the patient gave her written consent. When the patient arrived for the investigations, the consultant reviewed her in the presence of a nurse, repeated his explanation of the procedure and the risks, and she again gave her written consent.
During the endoscopy, antral biopsies were taken, which later confirmed acute-on-chronic gastritis and intestinal metaplasia. During the colonoscopy, extensive diverticular disease was discovered and the consultant found it difficult to negotiate part of the colon.
It was recorded that the patient was experiencing pain, so the procedure was abandoned. A perforation of the colon was suspected, so a CT scan was performed.
A perforation was identified, and after explaining this to the patient and her family, she was sent for emergency surgery. The consultant followed protocol in fully briefing the surgical team and his prompt action meant emergency surgery was performed the same day. The consultant visited the patient several times during her admission and saw her in his clinic after discharge.
The patient made a full recovery. Three years later, she brought a claim against the consultant.
Dr Clare Devlin: At the initial consultation in clinic, the patient had been clearly warned about the complication of perforation that took place. A few days after the initial consultation, the consultant again went over the procedures and the risks involved and obtained written confirmation of the patient's consent. Expert advice concluded that the claimant's solicitors would be unlikely to pursue the claim and indeed the claim was discontinued.
Dr Marika Davies: However, the patient then complained to the consultant’s Medical Council. We continued to reassure him that the expert felt his actions had been entirely appropriate. But, the complaint still required a robust response.
Dr Clare Devlin: Medical Protection helped to put together a comprehensive case that demonstrated reflection and insight and clearly outlined the communication between the consultant and the patient. It also set out the text book handling by the consultant of what is a well recognised complication.
Both Medical Protection, and the consultant, were delighted when the complaint was dismissed by the Medical Council with no further action.
Dr Vanessa Perrott: There is risk in almost everything we do as clinicians.
Having effective strategies to both convey the risk to the patient, and then check that they have understood those risks, is an essential part of shared decision making that goes above and beyond mere consent taking. Many of our members have found that the framework developed within Medical Protection called the ASSIST framework is something that really helps them with these very difficult conversations.
Dr Marika Davies: We can all take something from this case. Accurate and clear documentation is critical to defending any medicolegal case and, as in this one, it may be relied on years after the event.
This situation also highlights that a complication during a procedure isn’t always evidence of negligence as long as the patient has been warned of the risks, the procedure has been carried out to an acceptable standard and all reasonable steps have been taken to minimise the effects of the complication. And finally, the case demonstrates how important it is to be open and honest with patients, particularly about possible complications. The consultant’s approach didn’t prevent a complaint going to his Medical Council, but it did contribute to the dismissal of the case.