Knowledge Hub

06 October 2020

The case related to unacceptable failures to respond to the Claimant’s deteriorating condition during the post-operative period that delayed surgical intervention and led to her suffering avoidable pain and requiring an additional period of intensive care.

The Claimant’s past medical history included total abdominal hysterectomy and bilateral salpingo oophorectomy in 1990 and right hemicolectomy for bowel cancer in 2006.

In 2012, she developed a small incisional hernia in the site of her previous abdominal scar.

In March 2016, she was referred by her GP to West Cumberland Hospital for surgical opinion about a troublesome incisional hernia and, on 18 May 2016, she underwent open mesh repair of incisional hernia.  

In the year following the hernia repair, the Claimant developed an abscess and sought further help.  Around March 2017, she developed signs of infection at her previous incisional hernia repair site.  The infection subsequently burst, leaving an open wound.

On 25 May 2017, she was reviewed and advised to have the mesh surgically removed.  This was achieved on 19 July 2017.   It was described as draining of an abdominal wall abscess and removal of infected hernia mesh.

The post-operative records confirm that the Claimant deteriorated and the attending nurse had difficulty obtaining surgical review.

At around 14.30 hours on the 19 July 2017, the Claimant was reviewed by an ANP due to severe abdominal pain.  Her abdomen was noted to be distended with quiet bowel sounds.  The possibility of bowel perforation was raised.  Attempts to contact the on-call surgical team at Cumberland Infirmary were unsuccessful.  There is reference in the notes to a surgeon being contacted at home at 20.30 hours, but no record of the conversation.

At around 20.40 hours on 19 July 2017, the Claimant was reviewed by a medical SHO and was noted to be tachycardic.  She was given IV fluids and was kept nil by mouth whilst awaiting surgical review.

At around 22.15 hours, the surgical registrar at Cumberland Infirmary was contacted and advised about her condition.  The registrar’s recommendation was for a CT scan should her condition deteriorate.

The Claimant was next reviewed on 20 July 2017 at around 02.15 hours.  She was becoming increasingly agitated.   She was referred for a CT scan.

The CT report was available at around 06.25 hours on 20 July 2017 and showed free intra-abdominal fluid and air in keeping with a visceral perforation.  The surgical registrar was contacted who sought advice from the on-call surgical consultant.   As it was not clear from the operation what procedure had been performed, advice was given to contact the surgeon at 08.00 hours.

He was contacted at around 07.20 hours on 20 July 2017 and advised anaesthetic review and transfer to Cumberland Infirmary.

By the time the Claimant was admitted to Cumberland Infirmary, she was haemodynamically unstable with a NEWS of 7.  She was transferred to recovery for stabilisation prior to surgery.

On 20 July 2017, at around 13.30 hours, the Claimant underwent laparotomy, which revealed a perforation in the small bowel at the site of mesh removal with enteric contamination of the peritoneal cavity.   The area of perforation was exteriorised as a loop ileostomy and peritoneal lavage performed.   The abdominal wound was left open and the negative pressure vacuum system applied.

She was described as having suffered with intra-abdominal sepsis with small bowel perforation, with apparent circulatory and metabolic failure.

Post-operatively, the Claimant was admitted to intensive care with multi-organ failure.   She was returned to theatre on 6 August 2017 for incision and drainage of abdominal wall abscess secondary to a fistula from her ileostomy.   The recovery in intensive care was slowed due to difficulty in respiratory weaning, requiring tracheotomy.

She suffered from a high output ileostomy and abdominal wall fistula which was treated with total parenteral nutrition.

On 14 September 2017, the Claimant was transferred to West Cumberland Hospital for further rehabilitation.  She was discharged home on 19 December 2017.

Longden Walker and Renney obtained a breach of duty and causation report from a consultant general surgeon.   He confirmed that there were a series of missed opportunities to respond to the Claimant’s deteriorating condition following surgery that amounted to breaches of duty.   We alleged the following;

• There was an unacceptable failure on the part of the consultant to undertake a prompt review of the Claimant and arrange for early intervention when he was contacted at 20.30 hours on 19 July 2017, when he was contacted at home with the report that the Claimant was possibly suffering due to a complication and was complaining of severe abdominal pain and distension.
• There was an unacceptable failure on the part of the surgical registrar to arrange either an urgent CT scan or to arrange for the Claimant to be transferred to Cumberland Infirmary at 22.15 hours on 19 July 2017, when she was found to have signs of sepsis and raised lactate.
• There was a failure on the part of the surgical registrar to arrange for immediate transfer to Cumberland Infirmary when contacted at 02.15 hours on 20 July 2017.
• There was an unacceptable failure on the part of the surgical registrar to arrange for the Claimant’s immediate transfer to Cumberland Infirmary at 06.25 hours on 20 July 2017 following the CT scan.

Causation

An independent Professor and expert in general surgery was instructed on 29 May 2019 to prepare a report dealing with both breach of duty and causation.

The Professor was asked to consider the following:

1. The surgery undertaken in July 2017, including whether;

(a)   The surgery undertaken in July 2017 was an appropriate course of treatment for the Claimant’s underlying problems;

(b)   The Claimant was properly counselled about alternative  treatment options and the associated risks and benefits;

(c)     Whether the surgery itself was undertaken with appropriate skill and care.

2.     The post-operative care, including;

(a)   The identification of the development of post-operative complications;

(b)   When such complication should have been identified by competent clinicians and whether there was any delay in doing this;

(c)    Whether there was any delay in arranging an appropriate review and treatment.

3.     The Professor was also asked to comment on the likely injury that the Claimant suffered as a result of any substandard care, including whether he believed it is likely that;

(a)   She would have suffered less pain;

(b)   She would have avoided developing abscesses and infection;

(c)    Avoided the need for intensive care, dialysis and/or stoma;

(d)   Her treatment would have differed significantly in any other way;

(e)   She would likely have avoided the need for care and assistance.

The Professor was also asked to comment on whether he recommended obtaining a report from an expert in a different field.

With regards to causation, our expert confirmed in his report that had the Claimant received competent treatment, the consultant would have responded to the phone call at 20.30 hours on 19 July 2017, by reviewing her personally and that this would have led to the identification of the small perforation (following CT scan), transfer and surgery in the early hours of 20 July 2017.

He also confirmed that earlier surgery is likely to have avoided the Claimant suffering such a level of septic post-operative complications and resulted in her intensive care stay being shorted by around 1 week.

Had the Claimant received competent treatment from either the consultant or the surgical registrar, it was alleged that surgical intervention would have been more prompt and would have reduced her pain and suffering.

As the claim was limited to an additional stay in intensive care for one week, instructing Solicitors did not obtain condition and prognosis evidence.  The Professor was clear in his report that whilst the Claimant’s intensive care stay would have been shortened by around one week, she would still have suffered complications from the fistula and overactive ileostomy which were the main reasons for her protracted hospital stay.   The Professor also confirmed that the Claimant’s recovery at home would have been similar because of the ongoing problems with the overactive stoma which would have been the same.  She would still have required the surgery to reverse the ileostomy around the same time.

The Professor summarised his report and confirms that at most, earlier intervention would have spared the Claimant around one week in intensive care, but would not have been greatly different due to the nature of the operation being the same and the fact that the main contributing factors from a slowed recovery were her fistula and high output ileostomy which would have likely occurred in any event.

We therefore claimed for the following:

1. Additional pain and suffering caused by the delays in detecting the perforation operating on this.   This gave us around a 12 hour period.
2. An additional 1 week stay in intensive care as a result of the post-operative septic complications.

When we were instructed by the Claimant, we were investigating the alleged 14 hour delay in arranging a diagnostic scan after she was admitted in July 2017 for treatment relating to severe abdominal pain following surgery.   It was noted that the Claimant had required surgery to treat a perforated bowel. She then suffered septicaemia, organ failure and required intensive care.   The family were concerned that the outcome could have been different had she undergone a scan within a reasonable time frame.

It became clear when we received the report from the Professor that the outcome would not have been significantly different and this was a low value case and limited to an additional week stay in intensive care.

A Letter of Claim was sent to the Defendant on 27 January 2020.  The Letter of Response was received on the 4 June 2020 and this admitted both breach of duty and causation.

After negotiations an offer of £7,000 was received and settlement was then agreed.