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Video: Living up to expectations

Post date: 27/11/2018 | Time to read article: 6 mins

The information within this article was correct at the time of publishing. Last updated 12/03/2019

Dealing with claims accounts for about 1/5 of the cases we handle. This video examines a claim made against a consultant surgeon because he left out critical information from a patient’s notes.


Video transcription  

[Dr. Davies] Dealing with claims accounts for about a fifth of the cases we handle at Medical Protection. In the case we're about to look at, a claim was made against a consultant surgeon because he left out critical information from the patient's notes. The case provides valuable insight into how clinicians need to be open with their patients and the importance of managing patient's expectations. The patient, who was referred to a consultant cardiothoracic surgeon, was in his 60s and overweight. He was suffering from exercise-related angina. He had a range of risk factors for ischemic heart disease, including smoking, diabetes, and hypercholesterolemia. The angiography showed triple vessel coronary artery disease and he was referred for possible bypass surgery. The consultant's opinion was that the patient should have the operation, and he explained that the risk of death was less than 3%. Because his symptoms were so severe, the patient agreed to go ahead. The consultant also advised him to lose weight and to cut out the cigarettes before the operation. [[00:01:03]] The triple bypass went ahead without any complications, and the patient made a good recovery, leaving hospital after a week. However, he was not aware that a post-op chest X-ray had shown an elevation of the right hemidiaphragm, something the consultant decided not to share with the patient so as not to give him unnecessary cause for concern. During his post-op preview, the patient complained of shortness of breath. The consultant said things would be better soon and discharged him back to his own GP. A few weeks later, still suffering, the patient mentioned it to his cardiologist. A range of tests revealed he was suffering from various heart conditions, and the final diagnosis was right phrenic nerve palsy, secondary to surgical damage.

[Dr. Stacey] Unfortunately, in this case, the patient instructed solicitors to pursue a claim. Medical Protection encourages members to contact us at the earliest possible opportunity when they become or notice that there may be the possibility of a claim. This allows our specialist [[00:02:00]] Claims Assessment Team, to do an early analysis of the case. In that context, it's very important that we receive all the relevant documentation. That will include, for example, the general practice records, the hospital records, nursing records, private hospital records, to ensure that we have the full document set to do an initial analysis of the case and identify any strengths and weaknesses. In this case, there were several areas of vulnerability that were identified at an early stage. The risk of phrenic nerve injury wasn't portrayed to the patient in the context of the consent process. It could have been alleged that the phrenic nerve injury was a result of substandard surgical technique. In addition, the postoperative chest X-ray findings of an elevated right hemidiaphragm were not relayed to the patient and nor were the implications of that chest X-ray finding explained to the patient. Also, the patient's expectations in relation to the outcome of the procedure were not appropriately managed. [[00:03:00]] The vulnerabilities were discussed in detail with a member, and it was decided to instruct an expert to provide an opinion on the case. Thankfully, the expert was largely supportive of our member's involvement, although he did say that the patient should have been informed of the postoperative chest X-ray findings. The expert concluded that the phrenic nerve injury, was, in fact, a recognized complication of the procedure and that the risk was so rare it didn't merit a warning in the context of the consent process. On the basis of the supportive expert report, Medical Protection were able to serve a robust response, denying the allegations, which thankfully, led to the discontinuance of the claim.

[Dr. Perrott] So having a good strategy to understanding how to go through risks and explain them in a meaningful way to the patients, as well as having a good understanding medical-legally of where you might be at risk is something that we would consider a really worthwhile investment of your time. Medical Protection runs some workshops called [[00:03:59]] “Mastering Shared Decision Making,” where we do get you to practice those words authentic to your clinical context that might help you gain some confidence in risk communication and in engaging in a good shared decision-making process. There are so many risks around any procedure that understanding a way that you can process this risk in a meaningful way for the patient to understand and in a medical-legally safe way to protect yourself is really challenging. Medical Protection understands the complexities of shared decision-making and offers support in the form of webinars, workshops, and online resources to talk you through when it's too much, when it's too little, and what does good record keeping look like.

This is a valuable case in showing what can happen if information is emitted from notes, however good the intentions of the surgeon were. The consultant surgeon wasn't open about the complication. The patient should have known about it as soon [[00:05:00]] as it became apparent as part of the consenting process. He also didn't clarify that the patient would still suffer some symptoms of angina and dyspnea after the operation. This can lead to false expectations. And we know that full disclosure to the patient about their condition and likely outcome reduces the likelihood of them taking action later on. After all, we know that problems following surgery aren't necessarily down to medical negligence. The claim was defended successfully. While this was a positive outcome for our member, if he'd been open about the complication in the first place, the claim may never have arisen. So this case emphasizes how communicating information clearly to patients, and in a timely fashion, is key. Leaving out details, even if you're trying to protect your patient from all worry may only lead to a complaint or claim later on.



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