Medical Negligence

 

PACE Rehab Conference 2018 - Beyond the clinic room

Last week the annual PACE Rehabilitation Conference took place in London.  Julie Marsh, a specialist medical negligence claims solicitor at Boyes Turner, attended the event to learn more about transforming the lives of amputees.  

The aim of the day was to demonstrate the importance of enabling an amputee to live an active life through effective physiotherapy intervention, a trial of a prosthesis, occupational therapy input and most importantly, a multi-disciplinary approach to the rehabilitation process. 
Together with the team of PACE consultants, the programme included presentations from leaders in the field of prosthetics. Representatives from two mobility and prosthetics specialists, Ossur and Ottobock, talked about the newest developments in prosthetic provision and gave the audience a glimpse of the future, with implanted microprocessors controlling a lower limb device. 

There was a more detailed look at the Michelangelo hand, with a demonstration from two PACE clients.  Both had only been working with the upper limb prosthesis for about 12 months or so, and it became apparent just how much hard work and practice is needed to get the best from a prosthesis.  It was inspiring to watch the patients demonstrate using the hand to perform a variety of tasks, from the mundane picking up and opening a tin of beans, to the more complex task of taking apart and re-building a Lego tower. 

It was also interesting to be reminded of the benefit of a pre-amputation assessment, and how this gives the team at PACE Rehab an advantage and the patient a head start in the rehabilitation process.  The patient can look forward and focus much more on the next steps in their rehabilitation journey rather than becoming fixated on the loss of the limb – an additional and important psychological consideration. 

Another valuable reminder from the day was of how important it is to maintain awareness of the impact of a lower limb amputation on the remaining “good” limb, and the wear and tear that an amputee can place on that leg inadvertently through bad posture or altered gait. This highlighted the value of ongoing physiotherapy input to prevent the patient who successfully leaves the clinic room adopting bad habits to “make do” in an environment that challenges them with every step they take. 

Thank you to Scott Richardson and the PACE team for an interesting and thought-provoking programme. 

Our experienced amputation solicitors understand the importance of a multidisciplinary approach to rehabilitation and appropriate prosthetic provision. If you have suffered or expect to undergo an amputation caused by someone else’s negligence and want to find out more about how to claim, contact us at mednegclaims@boyesturner.com

What is Charcot foot?

Charcot foot is a serious, limb-threatening complication of diabetes in which the bones of the foot or ankle degenerate and become deformed, leading, if incorrectly treated, to disability and amputation.  

The condition arises from a combination of factors associated with diabetes. Diabetics with neuropathy (loss of sensation) have less feeling in their feet and may also have reduced muscle control and tissue damage. This affects their sense of balance and their walking gait and increases their risk of knocks, sprains and cuts, particularly to the soles of their feet. Diabetic neuropathy also reduces their ability to perceive pain following a minor injury to their feet, which means they can remain unaware of an easily treatable injury, such as a blister, until it becomes infected and ulcerated. As they continue to walk and put pressure on the affected foot , this increases the damage to the bones and tissues and their risk of serious disability.

Charcot foot develops over time but is often triggered by a minor injury, such as a sprain or twisted ankle, which remains untreated because it goes unnoticed.

Who is at risk of Charcot foot and resulting disability?

Diabetics are at risk of developing Charcot foot.

Their risk is increased by:

  • poorly controlled diabetes
  • reduced sensation (neuropathy) in the feet
  • impaired vision reducing the ability to carry out daily visual foot checks
  • existing ulceration

How can I reduce my risk of developing Charcot foot?

The key to reducing the risk of Charcot foot and other serious diabetic complications is good management of the diabetes, including good foot care, regular check-ups and prompt medical treatment of any injury (however minor) which could lead to more serious infection.

If an individual with diabetes has reduced sensation in their feet they must carry out daily visual foot checks to ensure that they seek help as soon as possible after a minor injury occurs. If they have impaired eyesight they should ask someone else to check their feet for them.  

They should see their GP immediately if their feet have:

  • Minor cuts
  • Blisters
  • Redness, warmth and swelling
  • Discharge or fluid oozing from the foot into socks or tights
  • Or if they feel generally unwell

Treatment from the GP might include:

  • Antibiotics
  • Advice to rest the foot
  • A review of their diabetic medication and management
  • Referral to a foot-care specialist
  • A personal care plan

What are the symptoms and treatment of Charcot foot?

Charcot foot symptoms can include:

  • Redness or swelling of the foot or ankle
  • The skin feels warmer at the site of the injury
  • A feeling of deep aching
  • Deformation of the foot

If an individual has a suspected or diagnosed Charcot foot, they should be referred immediately to a multidisciplinary foot care team. Treatment will involve reducing the pressure (or weight-bearing) and immobilising the foot in a plaster cast to allow it to heal in the correct position. The condition will be monitored by x rays and at regular appointments with a podiatrist.

Sufferers of Charcot foot and tissue damage through reduced blood supply are at high risk of limb-threatening infection. At the first sign of a new ulceration, wound, swelling or discolouration, the patient should be referred within 24 hours to a multidisciplinary foot care team for urgent treatment of their infection. Any delay can lead to amputation.

Boyes Turner’s clinical negligence team are experienced in acting for amputee clients who are living with serious disability caused by negligent medical treatment of diabetic complications, including Charcot foot.

If you have suffered or are expecting to undergo an amputation and would like to find out whether you have a claim, you can speak in confidence to one of our skilled amputation team at mednegclaims@boyesturner.com.

Amputation: What are the 3 most common causes we see?

Amputations are more common than you might think. The recent GIRFT report on vascular surgery puts the current number of lower limb amputations performed on the NHS each year at around 8,000, with an associated mortality rate of 7.5%. The good news is that with awareness, self-care and proper medical care, many amputations are preventable. For those whose avoidable amputations were caused by medical, employer or other road user negligence, financial help may be available through a legal claim.

Boyes Turner’s experienced amputation lawyers regularly help amputees restore their mobility and independence by securing funding to pay for rehabilitation, essential prosthetics, home adaptations and essential care and domestic assistance. Where the amputee is unable to return to their former employment, we can help alleviate the financial hardship that arises from their loss of earnings.

We asked our amputation specialist lawyers to tell us the most common causes of avoidable amputations which can give rise to a compensation claim:

Traumatic injury

Trauma, such as farm or factory accidents, where the injury arose as a result of unsafe working conditions or in an unsafe environment for visitors or children, are common causes of amputation claims against the employer or owner of the premises.

Road traffic accidents give rise to claims where a pedestrian, a cyclist, passenger in a car or taxi, pillion passenger on a motorbike or a bicycle, or another driver has been injured as a result of someone else’s negligent driving.

Complications of diabetes

With Type 2 diabetes on the increase, diabetes-related amputations are now performed at an alarming rate of 20 each day in England. Four out of five diabetes-related amputations are preventable, arising from minor foot conditions such as cuts, blisters, foot ulcers or sprains which develop into more serious infections or deformities such as Charcot foot.

Diabetes can lead to reduced blood circulation and loss of sensation in the sufferer’s feet, which means that they might not feel a blister or small cut until it has become infected or formed an ulcer. They might continue to walk on a sprained ankle until it develops signs of Charcot foot.

Diabetics and their health carers can reduce their risk of lower limb amputation by carrying out regular visual checks of their feet, promptly treating any signs of injury – cuts, blisters, discharge or oozing, redness, warmth or swelling – with rest, antibiotics if needed, and referral to foot care specialists.

Peripheral ischaemia

Peripheral ischaemia – a serious condition in which narrowing or blockage of the arteries restricts blood flow to a limb – was listed in a recent report on rising litigation costs by the Medical Protection Society (MPS) as one of the top five areas of substantial claims in GP practice.

If peripheral ischaemia is unrecognised or left untreated it can lead to ulcers, gangrene and amputation. Diabetics, smokers and sufferers of coronary artery disease are at increased risk, regardless of age, but 20% of adults over the age of 60 are believed to have some degree of peripheral artery disease.

Ischaemia to a limb can also be caused by surgical errors, such as mismanaged peri-operative anti-coagulation where the patient is known to be at risk of thrombosis or surgical injury to the popliteal artery.

If you have suffered an amputation or a serious injury with future risk of amputation as a result of someone else’s negligence, contact us on mednegclaims@boyesturner.com.

Vaginal birth after caesarean section (VBAC) - risks of rupture and RCOG recommendations

The RCOG Each Baby Counts programme’s recent report into the anaesthetic care which contributed to the serious brain injury, neonatal death and stillbirths suffered by 49 babies in 2015 highlights some of the highest risk areas in maternity patient safety. Aside from the essential teamwork, communication and forward planning which is needed to handle the multiple, time-sensitive, emergencies which occur in maternity units, the report emphasised that trial of vaginal birth after a previous caesarean (VBAC), if incorrectly counselled, undertaken and managed can result in uterine rupture, severely brain damaging the fetus and threatening the life of mother and baby. 

Serious injury was caused to a baby when signs of uterine rupture (including maternal tachycardia, breakthrough pain between contractions and a worrying CTG trace) were missed during a trial of VBAC labour. Despite these warning signs, the mother was incorrectly given syntocinon, a uterine stimulant, increasing the stress on her uterine scar. The report reiterated that pain breaking through a previously effective epidural in a woman with a history of uterine surgery must always trigger an obstetric review for scar rupture.

What are the risks of VBAC compared with a planned repeat caesarean section (ERCS)?

Assuming that delivery takes place at or after 39 weeks gestation in circumstances suitable for VBAC:

  • Planned VBAC has a 1 in 200 (0.5%) risk of uterine rupture, compared with 2 in 10 000 (0.02%) in a previously unscarred uterus. The risk increases when VBAC delivery is induced or labour is augmented with syntocinon.
  • The success rate for planned VBAC is 72-75% but increases if the mother has had a previous vaginal or successful VBAC delivery. If VBAC delivery is successful, it has fewer complications than ERCS.
  • Unsuccessful VBAC resulting in emergency caesarean section carries the greatest risk of adverse outcome.
  • The risk of unsuccessful VBAC and caesarean section increases if VBAC labour is induced or augmented.

Who is suitable for VBAC?

The RCOG guidelines for VBAC list the circumstances most suited to VBAC:

  • Singleton pregnancy (i.e. expecting one baby)
  • Cephalic presentation (baby is head down)
  • Pregnancy at 37 weeks or more
  • Single previous LSCS (lower segment caesarean section - scar across the lower part of the abdomen)

A successful VBAC delivery is more likely where the mother is taller, younger than 40, and has a BMI below 30, and the labour starts spontaneously before 40 weeks, and the baby is in vertex presentation with a birthweight below 4kg.

The risk of uterine rupture during VBAC increases with the mother’s age and the baby’s gestation and size, and where the mother’s last delivery took place less than 12 months previously.

Who can’t have a planned VBAC delivery?

Planned VBAC is contraindicated where there is:

  • A history of uterine rupture
  • Previous classical caesarean scar (scar goes vertically up the middle of the mother’s abdomen)
  • Placenta praevia (i.e. the placenta’s position would obstruct a vaginal delivery)
  • The mother has a history of other uterine surgery

Who decides whether the delivery will be by VBAC or ERCS?

The choice of delivery mode must be agreed by the mother and a senior obstetrician, based on her personal risk factors, before the planned date of delivery and after she has been counselled about the risks and the circumstances in which a trial of VBAC would be abandoned and caesarean section needed. All antenatal counselling must be documented in the medical records. If ERCS is planned, an agreed contingency plan for early spontaneous labour must be written in the records.

What additional safety measures are in place during VBAC delivery?

Labour must take place in a delivery suite equipped for continuous intrapartum care and monitoring, with facilities for immediate caesarean delivery and advanced neonatal resuscitation. The fetal heart must be continuously monitored electronically from onset of regular contractions throughout the VBAC, to ensure early detection of maternal or fetal compromise, obstructed labour or uterine scar rupture. The mother’s condition and progress of labour must be regularly monitored by one-to-one care.

What are the clinical signs of uterine rupture in labour?

The three classic signs of uterine rupture are pain, vaginal bleeding and fetal heart-rate abnormalities, but in 48% of all cases the scar breaks down without any maternal symptoms and is diagnosed later during surgery.

Clinical signs associated with uterine rupture include:

  • Abnormal CTG (most common sign)
  • Severe abdominal pain, particularly if the pain persists between contractions
  • Sudden scar tenderness
  • Abnormal vaginal bleeding
  • Haematuria (blood in the urine)
  • Previously efficient contractions stop 
  • Maternal tachycardia (elevated heart rate), hypotension (low blood pressure), fainting or shock
  • There is a change in abdominal shape and fetal heart-rate not detected at the previous transducer site
  • The fetus is no longer presenting properly

Suspected rupture of the uterine scar is an emergency requiring urgent caesarean section and neonatal resuscitation as the unborn baby is deprived of oxygen, leading to permanent brain damage or death.

As specialists in birth trauma claims, Boyes Turner’s medical negligence team are experienced in helping mothers and babies affected by uterine rupture during inappropriately counselled or managed VBAC deliveries.  

If you or your baby have suffered severe injury as a result of birth-related medical negligence contact one of our specialist solicitors by email mednegclaims@boyesturner.com.

Susan Brown awarded membership of exclusive Legal 500 Hall of Fame

Congratulations to Susan Brown, partner and clinical negligence team leader, from all at Boyes Turner, for her recent induction into the Legal 500 Hall of Fame.

Susan has long been recognised by all the major legal directories as one of the UK’s leading clinical negligence lawyers, but membership of the Legal 500 Hall of Fame is awarded exclusively to partners whose expertise places them at the pinnacle of the profession and who are constantly praised by their clients for continued excellence.

Susan’s immense experience and excellent judgement in high value child brain injury and maternal injury cases resulting from birth trauma and neonatal negligence regularly results in multi-million pound compensation awards for her clients. Her professionalism and incisive astuteness have earned her the respect and admiration of her colleagues, Counsel, medical experts and opponents, but it is her compassion for the injured children and her empathetic understanding of the devastating physical, emotional and financial impact of caring for a severely disabled child which results in such close and loyal relationships with her client families.

She has dedicated her career to making a lasting difference to the lives of severely disabled children and their families. We are delighted that Susan’s outstanding expertise and commitment to achieving the best possible results for her clients have been recognised in the Legal 500 Hall of Fame.

Read more about Susan Brown and the other partners who have been recognised in the Legal 500 Hall of Fame here.

60 Seconds with... Julie Marsh shares her experience with brain injury claims cases

During Boyes Turner’s campaign to raise awareness of brain injuries, we talked to Julie Marsh, a senior associate - solicitor in the clinical negligence group, about her experience of handling claims arising from delayed diagnosis and treatment of craniopharyngioma (a type of brain tumour).

What information do you need from an individual who has concerns about delays in the diagnosis and  treatment of a brain tumour? 

I need details about the timing of the onset of symptoms, when the symptoms were first noticed and what those symptoms were.  If the patient is a child, their family might be the first to notice that something is wrong, such as a change in behaviour, difficulties with walking or with vision. It is very important that I understand how the symptoms progressed over time, whether they deteriorated or stayed relatively stable, and over how long a period of time leading, finally, to a diagnosis.

It also helps to know when, and following which medical investigations, the diagnosis was made. Various different medical investigations can take place before a brain tumour is diagnosed.  

I need to understand what treatment has been received since the diagnosis, whether further treatment will be needed in future and what information, if any, the patient or their family have been given about the long term prognosis.

Can you investigate a case even if an individual is still having treatment?

Yes.  There are good reasons for contacting a solicitor as soon as you can after suffering any severe injury through medical negligence.

There are time limits associated with bringing claims. These vary depending on the patient’s age and the severity of their brain injury.

The sooner we can establish liability, the sooner we can obtain interim payments to help pay for care, specialist equipment, therapies and other costs arising out of the negligently caused injury and to ease the financial hardship that often arises following brain injury, often long before the case is finally concluded.

It is, however, important to have a clear diagnosis of a brain tumour, as the type of tumour will determine how the tumour has developed over time and its rate of growth – some cancers grow more quickly than others - and this is relevant to the claim.  

An ongoing investigation should not affect the provision of any treatment. In one of my cases, the client’s family approached me shortly after the diagnosis of brain tumour had been made. My client needed ongoing medical reviews and went on to have proton beam therapy and further surgery to treat the brain tumour. In the meantime, we were able to establish liability for the claim.

 How are claims arising from delayed diagnosis and treatment of brain tumour funded?

This type of claim is usually funded by way of a Conditional Fee Agreement (sometimes called a ‘No Win, No Fee Agreement’) backed by after-the-event insurance. This means that there are no upfront costs to the client to get the investigation underway and that the client will not be liable for any legal costs if the investigation is unsuccessful. In a successful claim, the Defendant pays the majority of the legal costs.  

We always discuss the funding arrangements for bringing a claim with a client at the outset, so that they understand the terms of the agreement and are entirely comfortable with them before any action is taken.  

Where a claim, even if successful on its merits, will not be financially viable for the claimant, I let them know at the outset.

How do you investigate whether a GP or the hospital acted negligently?

We investigate the treatment that the patient received from their GP or their hospital doctors by reviewing their medical records, detailing the recollections of the patient and their family in witness statements, and then obtaining the opinion of medical experts on the standard of the care that was given.

In cases involving a brain tumour, presentation can include issues with vision or with balance and coordination, and if the child has been assessed by a specialist, then it would be necessary to review the records from that assessment as well.

How do you calculate the level of compensation in a case arising from delay in diagnosis of craniopharyngioma? 

The valuation of any claim is entirely tailored to the individual client, the impact of their injury on their life and their personal circumstances. Here again, we work with experts, such as occupational therapists or visual rehabilitation experts, according to the client’s needs, to explore and quantify the injury that has been caused by the negligent delay.

In brain tumour cases we sometimes have to account for the fact that some degree of brain injury may well have occurred as a result of the tumour, even if it had been diagnosed correctly at an earlier time. It takes considerable expertise to ascertain what difference the delay in diagnosis made, in terms of the injury itself and the impact it will have on the client, (such as loss of vision), and their ability to function independently in future life. We then have to translate that into the financial cost of meeting their additional needs for care, aids and equipment, specialist education (SEN) in the case of a child, and so on, along with any future loss of earnings arising from reduced ability to work.

Why do you think it’s important for cases like this to be investigated?

The consequences of any delay in treatment can be devastating for the individual and their family, whether  physically, psychologically, educationally or financially. Through interim payments and compensation settlements we can alleviate our client’s financial hardship, facilitate rehabilitation and therapies, and restore a degree of independence. 

If you or a member of your family have suffered from a brain injury as a result of medical negligence contact our specialist solicitors on mednegclaims@boyesturner.com.

Brain Injury from Subarachnoid Haemorrhage

When subarachnoid haemorrhage (SAH) occurs, usually without warning, fast action is needed to admit the sufferer to hospital for live-saving surgery. National guidelines set an accepted deadline of 48 hours from incident to surgery. Delays lead to severe brain damage, disability and death.

Effects of brain injury from SAH

A subarachnoid haemorrhage causes damage to the brain, both from the dramatic reduction in blood supply (and oxygen) which follows the rupture of a blood vessel and from the pressure on the brain caused by the aneurysm or tumour which caused the haemorrhage and the bleeding into the subarachnoid space.

A patient with SAH remains at risk of further complications following their initial haemorrhage:

  • Rebleeding can occur soon after the first haemorrhage when the healed aneurysm ruptures again, exposing the patient to a high risk of permanent disability or death. This complication can be prevented by surgical repair to the aneurysm immediately after the first SAH.
     
  • Cerebral ischaemia from vasospasm - narrowing of the blood vessels in spasm - reduces the  blood supply to the brain, leading to increasing drowsiness and coma. The risk of secondary cerebral ischaemia can be reduced by medication given after the initial SAH.
     
  • Hydrocephalus - a build-up of fluid on the brain – can cause brain damage from increased intra-cranial pressure. Patients with hydrocephalus may experience headaches, vomiting, blurred vision and difficulty walking. Hydrocephalus is common after SAH has disrupted the production and drainage of CSF and may need treatment with a lumbar puncture or the temporary insertion of a shunt to facilitate drainage of the excess fluid from the brain. 

Patients who survive a subarachnoid haemorrhage may be left with long term effects from the damage to their brain. Depending on the severity and location within the brain of their SAH, they may have:

  • epilepsy (in 5% of SAH survivors )
  • cognitive dysfunction causing difficulties with memory, planning and concentration, which can affect even the simplest of tasks
  • extreme tiredness
  • headaches
  • problems with sleeping
  • weakness and loss of sensation in their arms and legs
  • difficulty distinguishing between hot and cold, which affects their ability to shower and carry out other activities safely
  • impairment to their sense of smell and taste
  • visual impairment, such as blurred or double vision, blind spots or black spots
  • difficulty understanding speech
  • emotional and psychological problems, ranging from depression to PTSD

How Boyes Turner can help

Where surgical treatment of SAH has been unacceptably delayed leading to additional severe brain injury and consequent disability, our experienced specialist brain injury team work hard to ensure that the full extent of our client’s additional injury and the impact on their life is properly assessed, rehabilitated, and compensated.

We work with trusted medical experts to assess whether the standard of care that the individual received from ambulance, accident and emergency and neurosurgical teams met acceptable standards for this emergency condition and whether early opportunities to identify and reduce the patient’s risk of cerebral aneurysm rupture were acted upon by those responsible for their earlier healthcare.

Once liability is established, we secure early interim payments to get rehabilitation and therapies underway, and to help pay for care, home adaptations and specialist equipment. We recognise the need for early intervention to optimise recovery from brain injury. Where our client was the major breadwinner, early interim payments can sometimes be obtained to ease the financial hardship that comes with being unable to return to work following a serious brain injury.

We then work with a range of experts, according to the circumstances of each individual’s case, including care and case managers, physiotherapists, occupational therapists, speech and language therapists and psychologists to assess the extent and lifelong impact of the individual’s brain injury and loss of function and to value their consequent needs. Our clients’ settlements are structured to provide optimum security and flexibility through tailor-made combinations of lump sum and index-linked annual payments (PPOs).

In cases where negligent medical care of a patient with SAH has led to their death, we support the deceased’s dependent family members in securing compensation for their loss.

If you are caring for someone who is suffering from the results of a delay in treatment of a subarachnoid haemorrhage due to medical negligence contact one of our brain injury solicitors - email mednegclaims@boyesturner.com.

Subarachnoid haemorrhage - a medical emergency

Subarachnoid haemorrhage (SAH) is a medical emergency. Fast admission to hospital for surgery is critical as any delay in surgical treatment can result in severe brain injury or death. Mortality and morbidity rates are high: 30% of people who suffer a SAH die within 24 hours; overall, around half of all cases of SAH result in death; and those who survive can experience long-term disability from brain damage. Getting It Right First Time’s (GIRFT) recent report into cranial neurosurgery highlighted surgery for SAH as one of the most time-critical procedures undertaken by cranial neurosurgeons. It is also one of the areas in which the GIRFT team found that critical delays in admission for surgery are putting patients’ lives at risk.

What is subarachnoid haemorrhage (SAH)?

A subarachnoid haemorrhage (SAH) is a type of stroke caused by bleeding into the subarachnoid space between the membranes on the surface of the brain. It is often, but not always, caused by a cerebral (brain) aneurysm – a bulge in a weakened area of a blood vessel – which ruptures and bleeds into the area surrounding the brain. SAH often occurs without warning but can sometimes follow activity which involves physical effort or straining.

Cerebral aneurysms are often symptomless until they rupture but can sometimes be detected before rupture if the patient starts experiencing symptoms, such as visual problems, pain on one side of the face or around the eye or persistent headaches, from pressure on the brain caused by the (unruptured) bulge in the blood vessel. If an aneurysm is detected before it ruptures, surgery is often recommended to prevent rupture leading to SAH.

Cerebral aneurysms are hard to predict or prevent but the following may increase an individual’s  risk: 

  • smoking
  • high blood pressure
  • excessive alcohol consumption
  • a family history of the condition
  • other rare conditions including autosomal dominant polycystic kidney disease (ADPKD)

Less common causes of SAH include:

  • abnormal development of blood vessels 
  • brain tumour (either cancerous or benign) causing damage to the blood vessels
  • brain infection, e.g. encephalitis
  • rare conditions which narrow or block the brain’s arteries
  • vasculitis – inflammation of the brain’s blood vessels, e.g. from infection

The symptoms of SAH:

  • sudden, agonising headache – often described as a blinding pain unlike anything experienced before, as if hit on the head
  • neck stiffness
  • nausea and vomiting
  • sensitivity to light (photophobia)
  • blurred or double vision
  • stroke-like symptoms – e.g. slurred speech or weakness on one side of the body
  • loss of consciousness or convulsions (fits)

What is the treatment for SAH?

If someone is suspected to have suffered an SAH they need to be admitted to hospital as an emergency. On admission to hospital the diagnosis of SAH will be confirmed by a CT scan. If the CT scan is negative but the patient’s symptoms suggest they have had an SAH, a lumbar puncture might be carried out to check the cerebro-spinal fluid (CSF) for evidence of bleeding into the brain.

If SAH is diagnosed or suspected, the patient will be transferred to a hospital offering cranial neurosurgery. If the haemorrhage has been caused by a brain aneurysm, surgical repair and prevention of further bleeding may take place, either by clipping – a surgical procedure involving craniotomy in which the blood vessel is clipped to prevent further bleeding - or coiling, in which platinum coils are fed into the aneurysm via a catheter inserted into a blood vessel in the patient’s groin or leg. Both procedures take place under general anaesthetic.

Medication may also be given:

  • To prevent secondary cerebral ischaemia – a complication of SAH in which brain damage occurs from reduced blood supply to the brain
  • To prevent seizures
  • To reduce sickness and vomiting

How common is SAH?

Around 6,000 people a year are admitted to hospitals in England with a subarachnoid haemorrhage. SAH is the cause of one in every 20 strokes in the UK. It can happen to people of all ages but is most common between the age of 45 and 70. Slightly more women suffer from SAH than men.

Deficiencies in medical treatment of SAH

Subarachnoid haemorrhage is a medical emergency. The recent GIRFT report into cranial neurosurgery described treatment of SAH as “one of the most time-critical procedures undertaken by cranial neurosurgeons, where bleeding from a ruptured cerebral aneurysm can cause rapid and extensive brain damage”. With SAH mortality rates of 30% within 24 hours and around half of all SAH cases leading to fatality, even a short delay in admission for surgery can be fatal. The longer the delay in treating SAH, the greater the risk of severe brain damage or death.

In 2013, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended that the nationally-agreed standard of 48 hours from diagnosis for surgical treatment of all bleeding brain aneurysms should be met consistently and comprehensively by all health care professionals treating these patients. In doing so it recommended a move towards seven day service provision.

In June 2018, the cranial neurosurgery GIRFT team found that 10% of patients do not receive surgery for subarachnoid haemorrhage within the target of 48 hours from diagnosis. Issues raised in the report about delays in throughput and patient pathways across cranial neurosurgery nationwide, such as lack of available theatres and beds, were thought to contribute to the SAH treatment delays, with the day-of-the-week of the patient’s admission disproportionately affecting the timing of their treatment. Despite the NCEPOD’s recommendation for seven-day service provision, SAH patients receiving treatment within the 48 hour target fell to 74% for patients admitted on a Friday and 58% for those admitted on a Saturday, compared with 83% for other days of the week. 

At Boyes Turner we are highly experienced in acting for brain injured and severely disabled clients whose injury arose in whole or in part from negligent delays in their medical treatment. These cases are complex and are often contested. They require specialist handling to disentangle the extent and impact of the negligently caused injury from the patient’s outcome if correct medical treatment had been given. We work hard to secure early admissions of liability, interim payments, and ultimately the best settlements for our clients which will meet their needs for care, therapies, specialist equipment and adapted accommodation. 

Boyes Turner welcome the findings and recommendations of the GIRFT team’s report into cranial neurosurgery in the hope that genuine improvements in healthcare will reduce the number of patients unnecessarily harmed by delays in treatment for SAH. Meanwhile, we will continue to work to protect the interests of those who have already been harmed or bereaved as a result of negligent healthcare. 

If you have suffered disability or bereavement from delayed medical treatment please contact our specialist lawyers - email them at mednegclaims@boyesturner.com.

Civil Liability Bill reaches the House of Commons

The Civil Liability Bill, which will reform the way the personal injury discount rate is to be set in future, has now completed its passage through the House of Lords and has reached the House of Commons.

Civil Liability Bill amendments

The bill has undergone two amendments during its three readings in the House of Lords, both in relation to timescales. The first amendment will allow the first review of the discount rate, which will undoubtedly increase it from minus 0.75%, to begin within 90 days of the bill receiving Royal Assent without the need for a specific commencement order – a minor amendment which signals the government’s intention to expedite the first review as soon as the bill becomes law.

The second amendment extends the maximum period between mandatory ongoing reviews of the discount rate from three years to five. Justice Minister, Lord Keen of Elie, explained the proposed extension of the review period as a potential way of reducing attempts to “game the system”, in which litigants try to delay or speed up claims settlements and trials to take advantage of current or anticipated discount rate benefits.  Speaking in the House of Lords at the Parliamentary committee stage of the bill’s journey towards enactment, former Justice Minister, Lord Faulks QC, a practising clinical negligence and personal injury lawyer, also referred to an accumulation of anecdotal evidence of gaming the system which is already occurring in anticipation of the expected discount rate increase with its inevitable lowering of multipliers and damages awards. He feared that such manoeuvring will take place almost continuously if the three-year review period is maintained, leading to an increase in unsettled claims as parties apply to adjourn or accelerate hearings to coincide with more favourable discount rates. The government argued that more frequent reviews would result in smaller, incremental changes which, in turn, would remove the need for parties to ‘game the system’, but conceded an extension of the review period to five years.

Discount rate change affects seriously injured claimants

The inevitable increase in the discount rate and consequent reduction of future loss awards for seriously injured claimants will undoubtedly profit the insurance industry. The Ministry of Justice has already asked insurers for their commitment to pass on the benefit of their financial gains from the new discount rate to their customers. Whether and to what extent the insurers will do so remains to be seen. 

Sadly, Boyes Turner’s personal injury team have had recent experience of defendant insurers trying to delay settlement of serious injury claims in the hope that delays will reduce the claimant’s compensation.

In clinical negligence, NHS Resolution have not resorted to such behaviour and Boyes Turner’s clinical negligence team continue to achieve high value awards for our severely disabled clients.

The Civil Liability Bill will now make its way through the House of Commons with the potential for further amendment, before finally being enacted as law. 

If you or a family member have suffered serious injury as a result of medical negligence contact our specialist medical negligence solicitors by email: mednegclaims@boyesturner.com.

Delays in cranial neurosurgery highlighted by latest GIRFT report

The latest report to be published by Getting It Right First Time (GIRFT) reveals the deficiencies and opportunities for improvement in the way cranial neurosurgery services are provided by the NHS. In contrast to previous GIRFT reports which have focussed on learning from variation in practises between NHS Trusts, GIRFT’s cranial neurosurgery report highlights that patient pathway inefficiencies and delays are being experienced in all of the 24 NHS hospitals which perform cranial neurosurgery, to the detriment of patient care and the frustration of the neurosurgeons.

The report specifically states that it is not a call for additional financial investment. Many of its recommendations can be implemented by NHS Trusts with minimal effort yet deliver an immediate impact on surgical capacity and throughput, resulting in more procedures taking place and patients who need urgent surgery receiving it faster. Implementation of its recommendations will optimise the use of existing resources to avoid delays and cancellations, free up hospital beds, deliver a better and faster service to patients whilst saving the NHS up to £16.4 million each year. NHS Improvement’s deadline for implementation of GIRFT’s cranial neurosurgery recommendations is June 2019.

What is cranial neurosurgery?

Cranial neurosurgery is a sub-specialty of neurosurgery which covers a range of surgical procedures performed on the brain or on the nerves in the skull. It includes the care and treatment of serious conditions and emergencies, such as traumatic brain injuries, intracranial bleeding and brain tumours, where timely surgery can save lives.  

Cranial neurosurgeons also carry out elective (non-emergency) surgery, such as relieving pain caused by nerve damage, and have a key role in monitoring patients with head injury.

In England, cranial neurosurgery is carried out in only 24 NHS hospitals which, together, admit 75,000 neurosurgery patients each year. In many of these cases, the patients were admitted for investigation, such as an MRI or CT scan or for monitoring after a head injury but did not have surgery. 40% of cranial neurosurgery admissions were for emergency treatment, most commonly for cranial trauma (head injury).

Cranial neurosurgery patients often need a lengthy stay in hospital owing to the severity of their condition and the longer recovery period from highly invasive surgery. For many, their care takes place in a critical care unit followed by extended monitoring on a ward, before moving on to rehabilitation. The average length of stay for patients following non-elective cranial neurosurgery was 19.4 days. 14% of patients stayed longer than 28 days.

Areas of concern arising from the report

GIRFT found that, without exception, all 24 NHS Trusts experience patient throughput delays which the frustrated neurosurgical teams believe are preventing them from seeing more patients and treating them sooner. After their treatment, patients are staying under the care of cranial neurosurgery longer than is clinically necessary, delaying the admission and treatment of new patients and resulting in high cancellation rates of those already admitted for elective surgery. 

Two-thirds of trusts fail to meet national 18-week referral-to-treatment targets for admitted neurosurgical patients, with eight trusts treating fewer than 60% of patients within the 18 week deadline. One in ten patients with subarachnoid haemorrhage or SAH (bleeding between the membranes surrounding the brain) do not receive surgery within the target time of 48 hours from diagnosis. This is a serious failing because any delay in treating SAH exposes the patient to the risk of severe brain damage or death.  

Even where cranial neurosurgery is not urgent, unnecessary stays in hospital cost the NHS more money, take up beds that delay treatment for other people and increase distress and infection risk to the patient.

The bottlenecks are experienced at every stage in the patient’s pathway. Patients have to wait for critical care beds to become available and these may be occupied by post-surgical patients awaiting discharge because the cranial neurosurgical centre has difficulty moving the patient on to other hospitals, rehabilitation centres or discharging them to a home setting with adequate rehabilitation support. The problem is compounded for tertiary (specialist treatment) hospitals because they are contractually obliged to accept referred patients requiring a specialist cranial neurosurgical procedure, whereas district general hospitals are not, and with their own stretched bed capacity and lack of rehabilitation resources, they can be unwilling or unable to take their post-surgical patient back.

Recommendations

The GIRFT cranial neurosurgery report recommends several ways in which hospitals can improve patient pathways to reduce delays and cancellations, speed up access to vital treatment, start post-operative rehabilitation sooner and improve patient experience:

  • Admitting patients on the day of surgery rather than in advance, particularly for minimally invasive procedures which don’t need anaesthetic and surgery for some brain tumours, to free up clinical care beds for more patients.
  • Reorganising the way operating theatres are used by designating one (existing, not new) theatre for acute procedures with open slots to cater for emergency admissions. This will  avoid disruption, cancellations or delays to patients already booked for elective procedures who are currently having to make way for emergency patients with higher clinical priority.
  • Speeding up discharge from cranial neurosurgery by making commissioning changes to compel referring hospitals to take their patients back once the patient is clinically ready. The success of this depends on better integration with community services to provide adequate and timely physiotherapy, OT and other rehabilitation support.
  • Avoiding thousands of neurosurgery admissions for non-surgical procedures, such as scans and post-operative checks, and consultant time spent in communicating scan results, which could be carried out by other multidisciplinary team members in outpatients or the patient’s home by phone or video-link.
  • Combining multiple consent and pre-admission clinic appointments to reduce the number of appointments that the patient needs to attend.
  • Avoiding delays by electronic information-sharing of patients’ scans and records between district general hospitals and the cranial neurosurgery centre, to avoid patients having to undergo repeated scans or long waits to be seen by a consultant because their information is not readily available.  

The GIRFT team envisaged that freeing up consultants from many of their 20,000 appointments each year will improve the use of resources, speed up discharge, reduce admissions and increase critical care bed capacity for when it is clinically required.

Freeing up just one extra bed per NHS trust per day would allow thousands more patients to receive the care of cranial neurosurgeons each year with no additional increase in resource – a goal that GIRFT believe is possible for each of the 24 NHS Trusts to achieve.

GIRFT estimate that implementation of their cranial neurosurgery recommendations will result in improved patient experience and outcomes whilst saving the NHS £16.4 million per year.

If you or a family member have suffered serious injury as a result of medical negligence during cranial neurosurgery call our specialist medical negligence solicitors by email mednegclaims@boyesturner.com.

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