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< Case 4 of 6 >

It started with an operation I’ve performed countless times as an orthopaedic consultant. It ended with something none of us ever wants to experience.

The operation was a hip replacement on a 73-year-old woman with multiple co-morbidities, including Type 2 diabetes mellitus, hypertension, recurrent cellulitis, and obesity. Everything had gone smoothly, but my handover to the weekend team had been impacted by my absence from the hospital due to a mild case of Covid.

Less than a week after the surgery, the patient tragically died as a result of sepsis.

Not long after hearing the news of her death, I got the call. The coroner wanted a statement from me, and had named me an Interested Person for the inquest.

Everything went very still. The world shrunk to just me and the phone, and what I was hearing in that moment. My mind went straight back to the handover. It had been hurried. There’d been no formal arrangements for senior cover. In my absence, I’d asked the ward team to keep a close eye on the patient and let me know of any problems.

In that moment, the end of my career felt close enough to touch.

I don’t actually remember calling Medical Protection, but I must have done so straight away. I do remember my medicolegal consultant taking me through the sequence of events leading up to the patient’s death. She was very calm, which really helped with the waves of panic surging through me.

The ward team had been in touch with me over the weekend, to let me know that the patient had developed a wound infection. I’d asked a consultant colleague to check on her. Things happened very fast after that. After developing sepsis and deteriorating rapidly, she was transferred to the intensive care unit, where she died as a result of multiorgan failure.

The patient’s family had raised several concerns with the coroner, all relating to the handover. They felt her medical history had not been properly considered in the peri-operative period. They were also critical of the lack of senior input over the weekend, and the delay in recognising the severity of the patient’s condition.

With the support of my medicolegal consultant, I drafted a statement explaining how illness had affected the handover. She also arranged for a solicitor to represent me at the inquest. Anticipating criticism over the lack of formal cover arrangements, he advised me to work with the hospital to address this issue ahead of the inquest. He also recommended I reflect on the importance of a comprehensive handover.

The inquest was daunting, to say the least. It’s always distressing to lose a patient. But faced with the anger and anguish of the family, you find yourself scrutinising your every action. There were difficult questions for me to answer in court. Thanks to my solicitor’s support before and during the inquest, I managed to answer them calmly.

The inquest concluded with the coroner issuing a Report to Prevent Future Deaths, and I was advised to self-refer to the GMC. Once again, I was at a precipice; this time facing the possibility of a formal GMC investigation.

And once again, Medical Protection were there for me. They helped to draft the self-referral document, and advised me on the appropriate CPD and self-reflection. Thanks to this, and the fact that I’d liaised with the hospital ahead of the inquest, the GMC closed the matter without a formal investigation.

I felt I’d not only been given back my livelihood, but my life – when something like this happens, there’s no such thing as normal anymore. The experience shook me to my core. It also taught me some vital lessons. More than anything, I will never again underestimate the importance of a properly structured handover – a critical link in the chain of patient care and safety. The issue of risk has really hit home with me. Medical Protection’s workshops on reducing risk through clear communication and better management of patient expectations were invaluable.

But what was truly priceless was the support I received. As a membership organisation, Medical Protection stresses it’s always there for members, and my medicolegal consultant and solicitor went above and beyond. I felt they were one step ahead of everything the whole time, with proactive guidance and moral support before, during, and after the inquest. A high proportion of the team are doctors, so they have forensic knowledge of the medicolegal landscape and are your best guide through it. Knowing they were there, around the clock, ready to fight my corner, saved me a lot of sleepless nights.

Get protection you can depend on from just £549*

This case is based on a real scenario, with some facts altered to preserve confidentiality.

*Cost shown is the annual membership price for a UK Medical Consultant working exclusively in the NHS. Subject to protection requirements and underwriting approval.

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