A Case in which the Claimant should have undergone Transurethral Resection and not Suprapubic Catheterisation. The following case was dealt with by Longden Walker and Renney Solicitors.
The case relates to alleged substandard care which led to the Claimant suffering a series of perforations to his bowel when he attended hospital to have a supra pubic catheter fitted.
The Claimant attended the hospital for the insertion of a supra pubic catheter under a local anaesthetic on 25 August 2015. The attempt caused him severe pain and the procedure was abandoned.
On 3 September 2015, he was noted to have E.coli urinary tract infection, sensitive to Gentamycin and Nitrofurantoin and resistant to Trimethoprim, Co Amoxiclav and Methicillin. On 5 September 2015, the Claimant was noted to be suffering from multi resistant E.coli. The white cell count in his urine was 115.
On 8 September 2015, the Claimant was admitted for right sigmoidoscopy and insertion of suprapubic catheter. The Claimant had previously undergone a hernia operation and adhesions were therefore likely to be present in his small bowel. It is the Claimant’s case that he was not suitable for blind puncture without the use of ultrasound in accordance with the NPSA and Barrass Guidelines in 2010. Following the procedure, the Claimant was in extreme discomfort. His condition did not improve and, the following day, he underwent a CT scan with IV contrast. The results were consistent with bladder perforation and pneumoperitoneum. A haematoma was also suggested.
The following day, the Claimant underwent a laparotomy. There was blood stained fluid in his abdomen and numerous bowel perforations (including multiple blind attempts were made to attempt to achieve suprapubic catheterisation). The perforations were closed and drains were placed.
On 14 September 2015, the Claimant developed tachycardia, sweating and tachypenia and was taken to theatre in a severely septic state having been found to have an ischaemic colon. The Claimant underwent colectomy and ileostomy. The operative findings were a small bowel injury that were intact but ischaemic large bowel with necrosis of the distal sigmoid. It is likely that the ischaemic colon was a direct result of the sepsis.
A supportive breach of duty (outlines where there had been failings in the standard of care) and causation (dealing with what the outcome should have been if there had been no breaches of duty of care) report from an expert Consultant Urologist, was obtained. A causation report was also obtained from an expert Consultant Colorectal Surgeon. Condition and Prognosis Reports were obtained from the Consultant Urologist, the Consultant Colorectal Surgeon and an expert Consultant Psychiatrist. An expert care report was also obtained in this case.
The claim was solely pursued against Yeovil District Hospital NHS Foundation Trust.
Breach of Duty and Causation
Based on our expert evidence, the following breaches of duty were alleged;
- Failing to offer the Claimant a transurethral resection.
- Failing to inform the Claimant that the successful transurethral resection would mean that he would not be reliant on a catheter on the balance of probabilities.
- Failing to inform, or adequately inform the Claimant of the risks and disadvantages of suprapubic catheterisation compared with intermittent self-catheterisation, namely stone formation and the diminishing life expectancy.
- Failing to point out the advantages of intermittent self-catheterisation over suprapubic catheterisation.
- Failing to ensure that the Claimant was aware that there were treatment options, such as intermittent self-catheterisation and transurethral resection, which did not carry the risk of bowel injury.
- Failing to ensure the Claimant underwent a trial of intermittent self-catheterisation.
- Failing to offer reasonable variable treatments.
- Failing to adequately consent the Claimant.
Procedure under Local Anaesthetic
- Failing to ensure the urine was not infected, thus exposing the Claimant to the risk of gram negative sepsis.
Procedure under General Anaesthetic
- Failing to delay the procedure until the extended Beta Lactomase E.coli infection was treated.
- Failing to ensure the Claimant’s head was lowered on the operating table. This would have given the optimal chance for the bowel to fall in a cranial direction, reducing the chance of bowel damage.
- Proceeding to blind puncture the patient with a history of pelvic surgery and known diverticulum who already had a failed attempt. It was the Claimant’s case that he should have undergone a catheter placement under ultrasound, or if that was not available, an abdominal ultrasound should have been undertaken prior to the procedure to determine whether there were any small bowel loops in front of the bladder or surgery should have been preceded by way of an open suprapubic catheter placement.
- Carrying out multiple bi-punctures.
- Causing four perforations to the Claimant’s bowel.
- Failing to ensure the procedure was carried out by a urologist with appropriate skill and experience as indicated by a consultant recorded view of 8 September 2015 that it required a consultant.
- Failing to record the number of attempts to puncture the bladder, when to do so, risk of infection, bowel perforation.
- Failing to provide covering antibiotics, where there has been bladder puncture in the presence of a dwelling urethral catheter and the presence of inadequately treating E.coli.
- Failing to carry out a CT with contrast supplemented by a CT cystogram on 8 September 2015.
- Failing to ensure that the Claimant was returned to surgery on 9 September 2015.
The Claimant’s case on causation was as follows;
- Had he been offered the choice of transurethral resection he would likely have opted for the treatment, given that it would have offered the prospect of being catheter free. On the balance of probabilities, transurethral resection would have been successful and he would have been able to pass urine, albeit with a larger than normal post-void residue.
- Further or alternatively, had the risks of suprapubic catheterisation compared with intermittent self-catheterisation been explained to the Claimant, and he had been provided with a trial of ISC, it is likely that he would have opted for ISC and would have avoided all the sequelae.
- If the suprapubic catheter had been placed whilst he was in a head down position under ultrasound guidance or with prior abdominal ultrasound or by open surgery, bladder and bowel injuries would have been avoided.
- As a result of the multiple blind punctures, four separate punctures of the small bowel were caused and damage deeply situated into the ileus muscle wall behind the structures which should have been encountered during this procedure. Urine infected with BSBL leaked into the peritoneum, along with bowel contents. As a result of this, the Claimant suffered the following
- Peritonitis and the need for laparotomy on 10 September 2015 to close the perforation;
- Sepsis causing ischaemic large bowel requiring colectomy and ileostomy on 15 September 2015;
- Fistula requiring repair;
- Prolonged hospital stay;
- Complete loss of normal bowel function with reliance on an ileostomy;
- Reliance on a suprapubic catheter, which was a sub optimal way of managing his urinary retention;
- The loss of treatment option of a transurethral resection, sepsis, multiple bowel operations means the nerves supplied to the bladder will have been further affected and there is no chance of a transurethral resection with resulting spontaneous voiding;
- Incisional hernia;
- A parastomal hernia;
- Risk of adhesions;
- Post-operative delirium lasting 2 days;
- An adjustment disorder with symptoms of anxiety and depression;
- Risk of metabolic disorders associated with fluid loss resulting in dehydration and increased chance of urine infection and stone formation.
- As a result of the Defendant’s alleged negligence, the Claimant had a suprapubic catheter and ileostomy. He no longer plays golf or runs. His work has been affected as he is unable to lift anything heavy and he has issues around using Client’s toilets. He is socially isolated. He has difficulties with tasks of everyday living. He is unable to be intimate with his wife and his marriage is strained as a result.
- The Claimant has stones and infection in the bladder that required treatment. He could be taught intermittent self-catheterisation although this is complicated by an enlarged prostate. If successful, the risk of stone formation and significant infection is much lower. His bladder stones are causing pain but can be treated endoscopically.
- The Claimant suffers from intermittent abdominal pain around the parastomal hernia. He has a midline laparotomy scar approximately 30cm in length. He has a parastomal hernia, which is a risk of strangulation. He has an incisional hernia. These require repair, which requires a substantial morbidity risk. He has adhesions that may cause small bowel obstruction. He may elect to have the ileostomy reversed. He takes Imodium daily.
- The Claimant suffered a short period of delirium during the time he was acutely septic when in ITU. He is suffering from an adjustment disorder with symptoms of anxiety and depression. He requires CBT.
Process of Litigation
A Letter of Claim was sent to the Defendant Trust on 26 February 2018. The Defendant’s Letter of Response was received on 10 December 2018. The Defendant denied liability in full in the case.
Court proceedings were therefore issued in the Royal Courts of Justice on 16 January 2020. Proceedings were served on the Defendant on 12 May 2020.
The Defendant denied there was a failure to offer the transurethral resection. The Defendant stated that Claimant was fully informed of the various treatment options available to him and of the pros and cons of the same and elected to undergo insertion of a suprapubic catheter.
The Defendant also stated the Claimant was fully informed of the risk of injury to the small bowel occurring during insertion of an SPC.
With regards to the procedure under the general anaesthetic, the Defendant stated that the inadvertent damage to the adjacent small bowel is a well-recognised non negligent complication of the insertion of a SPC. They also stated the procedure was appropriately undertaken and that the damage to the bowel was a recognised non negligent complication.
Notwithstanding this in July 2020, the Defendant made a time limited offer of £250,000 in full and final settlement of the Claimant’s claim. This was rejected.
Negotiations ensued and we were able to secure an agreed settlement of £375,000.