Surgery negligence news

 

Jan's amputation story: Little victories; lots of frustrations

When 58-year-old nurse, Jan, went into hospital to have her colostomy reversed, she could never have imagined how much her life was about to change.

Jan had lived with the colostomy for a year after a bowel resection for diverticulitis and the reversal operation should have been the final stage towards recovery. She awoke after the surgery in excruciating pain and was given an epidural for pain relief. Over the next two days, her condition was allowed to deteriorate, developing into sepsis. She was treated with ineffective antibiotics and when she was finally taken back to the operating theatre, investigative surgery revealed a leak from her perforated bowel. Despite her continued post-operative deterioration, signs of sepsis and necrotising fasciitis were mistaken for post-surgical bruising and her ineffective antibiotic treatment regime continued.

A change of shift finally brought a nurse who had experience of nursing necrotising fasciitis. The nurse “smelled rotting flesh” and, recognising the signs, called the surgeon to review Jan’s condition. Jan was taken back to theatre for extensive debridement of her right flank, lower back and thigh. “It was huge,” says Jan, “like a shark bite,” and left deep scarring that she still finds upsetting whenever she looks in the mirror.

The infection raged on and Jan underwent multiple further debridement procedures. She became increasingly unwell with septic shock, ending up on the ITU suffering from multi-system organ failure, ischaemia, brachial thrombosis and extensive peripheral vascular compromise, causing gangrene in her hands and feet.

Jan has no recollection of these events throughout which she was semi-conscious from the strong pain medication. Jan’s first recollection is of waking up ten weeks after the original resection operation, completely unaware of her condition. “When I eventually came to, I remember looking at my hand. I couldn’t comprehend it at all.” She struggled to come to terms with the fact that she was potentially facing amputations. It was only months later, whilst sitting in a café with her daughter, that Jan asked to be told what had happened.

Jan was transferred to the Royal Free for the next stage of her treatment; “They did a skin graft on my thigh, removed my left hand and half my fingers [on the right hand], my toes on my left foot and half of my right foot. That was the most awful time for me, probably the worst time ever in my eleven months in hospital.”

Left in a closed room, isolated from the rest of the ward, with multiple recent amputations and the physical and emotional after-effects of her life-threatening illness, Jan received no counselling or psychological support. “I was very lonely. I was away from the nurses’ station and I was scared. I remember the physios trying to get me up walking. They took me down to the gym and I collapsed. I don’t think they believed how much pain I was in.”

The loss of the right leg came in stages. Initially, Jan had a mid-tarsal amputation leaving her with half a foot which never healed, despite five or six operations. 

“I was in so much pain from the sinus wound in the foot, especially when I had the dressings done. They gave me such strong painkillers that I was actually nodding off when I was eating. I remember the wound nurse from Hillingdon coming to see the wound on my foot and I said, ‘I’ve had enough. Let’s just take it off’. When I woke up after the below-knee amputation, it was fantastic. I didn’t have the pain. I was sore but I didn’t have the pain that I had before. When the physio came to see me and told me that he had come to help me with transferring to a wheelchair, I said, ‘What, like this?’ and I got up and did it. Little victories.”

Given her extensive disabilities, Jan understood that it was inevitable that she should lose her job as a nurse, but that didn’t make the news any easier to take. “I had been nursing since I was 17 and worked right up until the day before this all started. My manager and the HR came to see me while I was in hospital. That was very upsetting. I knew I wouldn’t be able to go back to work but when they actually came in to see me and told me…it was very upsetting.”

Going home was tough, bringing Jan face to face with the devastating impact that her sepsis, multiple amputations and consequent disability has had on her previously contented life.

“Three days before I came home the occupational therapist took me home [to see how she would cope]. I remember walking in there and looking at the pictures on the wall of our wedding two years earlier and bursting into tears.” Turning to her husband, Martin, Jan says; “Our relationship is very different. You’re still my husband but you are my carer.”

Ever-supportive, Martin, responds philosophically; “I’ve got another role as a carer and that takes precedence over all the other feelings. What’s happened has happened and we’ve just got to accept it.”

Martin was still working when Jan was discharged from hospital and in the absence of adequate provision for her safety and care, he did what he could to enable her to cope at home. “We had a big meeting towards the end of my time in hospital with the OT, the doctors and the physios,” recalls Jan, “They said I didn’t need a stair-lift. Apparently, you don’t need a stairlift if you can’t manage the stairs - you either have a room upstairs with everything in it or a commode downstairs.” Undeterred, Martin installed a stairlift before Jan came home. Without it, she wouldn’t have been able to cope. 

Martin also extended his daily routine to give him time to help Jan with her personal hygiene before he set off for work. Jan recalls; “I was given an ileostomy, which they tried to get me to manage. An ileostomy is not like a colostomy - it will work when it wants to work - so, all I remember about when I got home is being in the back bedroom, covered in pooh all around me, because it had leaked. Martin had to get up for work at half past two every morning, but he used to do me first before he went to work. Then the carer would come in later and it would be everywhere again. At first, they were giving me bed baths, but when I was able to move onto the commode, they would wheel me through into the bathroom and I would have to sit on the toilet to be washed. That was awful. I hated it. We had a bath but I couldn’t get into the bath. We had to fight with the council to have a walk-in shower put in.”

Given the almost complete loss of her hands and feet, Jan found the inadequacy of her NHS prosthetic provision, and the lack of compassion which accompanied it, particularly upsetting; “When we were at the Royal Free, the OT just handed me a catalogue of all the implements I could use without hands, and said, ‘All we will give you is cosmetic, you’ll get nothing else’. At Stanmore, the cosmetic arm they gave me fell off and the thing they gave me for my foot had a calliper on it. It was just awful.” Later, at the John Radcliffe, Oxford, she was offered a hook. “That was more of a hindrance than a help.” 

Jan and Martin are gradually adapting their lives and environment to meet Jan’s extensive needs. They have moved to a one-level home with a bigger bathroom and a walk-in shower, with further adaptations underway, but Jan has no intention of spending her days sitting waiting for Martin to come home.

 “At home I was very isolated. To begin with, I couldn’t drive, so I couldn’t go anywhere. I was housebound.” Jan is delighted that they have addressed the problem of her isolation with an adapted car which, at last, restores some of her independence. “I’m back driving, which is fantastic. My car’s been adapted. I use my left foot to drive with, so the accelerator is now on the left side. That took some getting used to. Martin can still use it because the left accelerator goes up and the right one comes down. It’s automatic and I have a ball on the steering wheel. I love driving, just my little dog, Molly, and me.”

For all Jan’s enthusiasm, Martin can’t help worrying; “I hate her driving. It’s good, but I still don’t like her driving.”

Having watched Jan’s struggles, it’s only natural that Martin worries, but Jan has learned to celebrate every little step towards her independence. Jan explains, “I would rather try and do things on my own, so I do, and he gets cross with me. I get very, very frustrated. We went out for a meal two weeks ago and I said to the waiter, ‘Would you ask the chef to cut my meat up for me please?’ The waiter asked whether that was all I wanted cut up, but I knew I could manage the rest. That was excellent.”

Little victories. Lots of frustrations. Little things we take for granted that Jan can no longer do.

“I still have tears, but the tears now are really frustration. It’s so hard. I was taking things out of the tumble dryer yesterday and trying to fold them up. I can just about manage to cook but I have to ask Martin to take things out of the oven for me. I can’t peel an apple…”

That’s no hardship,” Martin intervenes. He’s always happy to help.

“I know it’s no hardship to ask you,” says Jan, “but I’d rather do it myself.”

Jan would also rather do her own shopping; “I don’t like Martin going to do the shopping all the time. I like to go, but you’ve got to plan ahead all the time. I drive up to Tesco but it’s no good using my wheelchair because all I can do is put a basket on my lap and I can’t put much in there. So, I go in with my stick and ask for an electric wheelchair, but [when she last went] there were none left. So, I managed by pushing a trolley around. By the end of it they were very sweet. They could obviously see me struggling and they came over and offered me a staff member to push me around in a wheelchair and do my shopping with me, which was brilliant. When I went in again yesterday to do some shopping, they had got some new scooters.”

Jan approached Boyes Turner after her previous solicitors left it until a month before her limitation deadline expired to tell her they couldn’t pursue her claim. “I thought it was finished and I was broken hearted.” However, Boyes Turner were able to overcome these difficulties and obtained a substantial settlement for Jan, bringing to a satisfactory conclusion this highly complex and strongly contested claim.

With the legal case behind her and the security of knowing that she has financial provision for her needs now and in the future, we asked Jan to reflect on the claim; “The biggest relief is that it’s finished. There is no more fighting for anything. They still haven’t said, ‘Sorry, we made a mistake,’ but I suppose they don’t just write out a cheque without some acceptance that they were to blame.”

If you or a loved one have suffered or are expected to undergo amputation as a result of medical negligence and you would like to find out more about making a claim, contact us by email at claimsadvice@boyesturner.com.

How failing to gain proper, informed consent before spinal surgery can lead to negligence claims

Doctors have a duty to obtain proper, informed consent from you, as their patients. Where, through the doctor’s failure to provide sufficient information, a procedure or treatment is carried out without your informed consent, an action may lie in negligence for breach of duty.
There are two essential elements to such a claim:

  1. The doctor was negligent in the provision of advice and/or information on the proposed treatment; and, 
  2. The negligence has caused you to suffer pain, suffering, loss and damage.

Inherent to this second requirement is that but for the defendant’s negligence, it is unlikely you would have suffered the adverse outcome for which the claim is brought. In other words, if you were given the correct advice, you would not have gone ahead with the procedure at that time and/or not at all. 

How do I give informed consent?

Signing a consent form is not necessarily conclusive on the issue of consent. In cases where the prospective claimant has suffered an adverse consequence following treatment, circumstances surrounding the consent process usually form part of the pre-action investigation, including what was said at the time and by whom.

The Supreme Court’s decision in Montgomery v Lanarkshire Health Board [2015] UKSC 11 reaffirmed the nature of doctors’ duties in advising and obtaining informed consent to medical treatment.

Mrs Montgomery, diabetic and of small stature, was expecting a child. It was well known at that time that diabetes mellitus in the mother carried a risk of a larger baby. The case therefore concerned the failure in the duty owed by the defendant doctor to Mrs Montgomery to advise of the particular risks of shoulder dystocia if her baby were born by vaginal delivery, and to provide her with alternative options in respect of the delivery of her baby. During the natural delivery, the baby’s shoulders became lodged in the birth canal and as a result the baby boy was starved of oxygen, suffering a brachial plexus injury and later being diagnosed with cerebral palsy.

The Court found, in Mrs Montgomery’s favour, that she should have been advised of the risk of shoulder dystocia, and had she have been, she would have opted to give birth by caesarean section.

“An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken. The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it. [87]”

Montgomery reaffirmed three important points: 

  1. The importance of patients’ autonomy.  Patients have the right to be involved in discussions and make informed decisions about their care; as such decisions affect their lives and bodies. It is for the doctor to advise, and the patient to decide.

“A rule requiring a doctor to abstain from performing an operation without the informed consent of a patient serves two purposes. It tends to avoid the occurrence of the particular physical injury the risk of which the patient is not prepared to accept. It also ensures that due respect is given to the autonomy and dignity of each patient. (Chester v Afshar, [18])”

  1. That doctor’s duties extend further than providing their patients with percentages; it involves a dialogue between him and his patient. The information given to patients should reflect: the nature of risk, the likely effect such risk could have on the life of the patient, the benefits of the treatment, any alternative treatments, and the risks associated with those alternative treatments. The doctor’s advisory role will only be performed effectively if the information provided is comprehensible.
     
  2. The test of materiality. The assessment of the materiality of a particular risk is dependent on both the specific facts of the claim and on the individual patient. It is therefore important that a doctor considers what a reasonable person in the patient’s position would be likely to attach significance to, and what that particular patient would want to know about or relating to the proposed procedure. This includes, but isn’t simply confined to, the chances of risks materialising, but also:
  • Advice on alternative (conservative) treatments (Montgomery, Hassell v Hillingdon Hospitals NHS Foundation Trust)
    There will always be alternatives, even if the alternative is no treatment. For instance, In Hassell, there were alternatives in the form of conservative management with painkillers or physiotherapy which the surgeon failed to advise. 
  • Changes to the treatment (Crossman v St George’s Healthcare
    Doctors are under a duty to fully involve patients in decision-making and not make paternalistic decisions without consulting the patient.

In Crossman, the patient suffered from numbness in his arm as well as pain and restriction of movement in his neck. Minor compression of the spinal cord was visible upon an MRI scan. In light of the scan, various options were discussed and the consultant advised conservative treatment, physiotherapy and a review within 3 months. Subsequently, a letter was sent to summon the claimant for operative treatment. The claimant queried this, but complied, as otherwise he would go to bottom of the waiting list. The claimant therefore had the operation and, although it was not performed negligently, suffered nerve damage. It was agreed that the risk of this result was less than 1%, and further agreed that, if the management plan had been followed as intended, the claimant would have had the same surgery 3 month later with the same level of risk. The case is one of very limited cases which have succeeded on ‘but for’ causation, discussed further below in reference to Chester.

  • Who would be operating (Jones v Royal Devon and Exeter NHS Foundation Trust)
    In Jones, the patient was referred to a particular consultant for her back pain. However, when she later underwent bilateral decompression surgery it was performed by a different surgeon. As a result of the surgery, she suffered a dural tear and damage to the nerve roots in the cauda equina. This was a recognised risk of the operation and was not in itself negligent; however, she succeeded in her claim on the basis that she had not consented to the operation being performed by the particular surgeon that performed it. 
  • The timing of the advice (Thefaut v Johnson; Hassell v Hillingdon)
    There must be adequate time and space for there to be a reasonable dialogue between doctor and patient, and time for the patient to consider the options and advice. This is not satisfied by a short telephone call, nor is it appropriate to give new information to the patient on the morning of the surgery (save if it is an emergency).
    In Hassell, the patient was asked to sign a consent form just as she was taken into surgery. Although the consent form warned of the risk of spinal cord surgery (which the experts agreed was sufficient warning of the risk of paralysis), it was given first a few moments before surgery and did not allow the patient an opportunity to reflect.

The ‘therapeutic exception’ is maintained. If a doctor reasonably considered that the disclosure would be seriously detrimental to the patient’s health, they are entitled to withhold information.

In addition to expert evidence, the claimant’s own factual evidence of his/her personal circumstances and evaluation of the nature, magnitude and potential consequences of the relevant risk, are likely to play an important part in whether or not the defendant’s failure to provide information amounts to a breach of duty. 

What will help my claim to succeed?

An essential part of any claim in negligence is to satisfy causation in both fact and in law. The considerations are two-fold: 

  • Whether the defendant’s conduct actually made a difference in reality, usually through the ‘but for’ test: but for the defendant’s negligence, would the claimant have suffered loss or injury? 
  • Whether any such difference is fairly attributable to the defendant, usually through ‘reasonable foreseeability’ considerations. 

In consent cases, what is often crucial in establishing causation is the claimant’s factual evidence as to the decision they would have made had they received proper advice.

However, the decision in Chester v Afshar [2005] 1 AC 134 infamously represents a “departure from traditional causation principles” (Chester, [24]). 

The case concerns a neurosurgeon’s failure to warn the claimant of a small but unavoidable risk of surgery. The 1-2% risk was neither created nor increased by the defendant’s failure to warn. Although the surgery was performed competently, the risk eventuated, and the claimant suffered nerve damage.

The claimant established at trial that, had she been properly advised, she would not have had the same surgery on the day itself, but neither did she allege that she would never have had the surgery at all. Accordingly, the court proceeded on the basis that she would have had the same surgery at an unknown later time. While the risks might have been the same in any future operation, the likelihood of that risk materialising was not the same; it was more likely than not that the same damage would not have been suffered by the claimant at a later date. 

The claim would have failed on traditional causation principles, establishing factual causation but failing to show legal causation. In Duce v Worcestershire Acute Hospitals NHS Trust, Hamblen LJ explained this as follows: 

“That modification was to treat a “but for” cause that was not an effective cause as a sufficient cause in law in the “unusual” circumstances of the case. [66]”

In allowing the claim on policy grounds, the House of Lords emphasised how the duty of a surgeon to warn of the dangers inherent in an operation is intended to minimise the risk to the patient and enable them to make an informed choice whether to undergo the treatment, at whose hands, and when. On the facts, the surgeon’s failure to do violated the claimant’s right to choose for herself, even if he did not increase the risk to her. 

The function of the law was to enable rights to be vindicated and to provide remedies when duties have been breach. Unless that was done in the instant case the duty to warn would be a hollow one. On policy grounds the test of causation was satisfied in the instant case. The risk that eventuated was within the scope of the duty to warn so that the injury could be regarded as having been caused, in the legal sense, by the breach of that duty.

In subsequent cases, the Court of Appeal has consistently confined it to its own facts, declining attempts to extend it to further factual scenarios.

In summary, recent case-law tells us… 

  • A negligent non-disclosure of information by the doctor cannot of itself create a free-standing claim (Diamond v Royal Devon & Exeter NHS Foundation).
  • The principle in Chester is a narrow decision with little application to further cases. It can only apply where a claimant proves only that, if advised correctly, they would have undergone the treatment complained of but at a later time, with an identical risk of harm. 
  • Where a claimant would have had the treatment at the same time, Duce confirms the claim would fail. 
  • If the claimant would not have had the treatment at all, then causation succeeds on conventional principles, as in Montgomery.

The duty to warn only extends to material risks.

There must be a close nexus in fact between the initial wrongful advice and the ultimate injury.
If the claimant would have suffered the injury in any event, or if there was a break in the chain of causation, the claim will fail.

How can Boyes Turner help?

Spinal injuries have a devastating effect on lives. A significant period of readjustment and support is required to adapt to the life changing event. At a distressing time, our specialist spinal injury lawyers can offer straightforward and clear advice and assistance. There is no cost to our clients, should the claim be unsuccessful, and our approach is to work with our client and their family as necessary to ensure maximum compensation to help rebuild their lives.

If you have suffered a spinal injury and would like to enquire if you have a claim, you can contact our team at mednegclaims@boyesturner.com.

Valuing an amputation claim - prosthetic provision

At Boyes Turner, we understand that you cannot put a price on the loss of a limb. However, as experts in medical negligence and personal injury amputation claims, we also understand that it is imperative that any award of compensation fully takes into account the cost of the amputee’s current and future prosthetic needs.

How are personal injury damages calculated?

Under English Law, there are two main elements which make up the value of a personal injury compensation award. The first part of the compensation reflects pain, suffering and loss of amenity experienced by the injured person as a result of the defendant’s negligence, and is known as ‘general damages’. These awards generally follow set guidelines and are based on what the court has previously ruled as an appropriate level of compensation for that particular injury. The second part of the compensation reflects the individual’s additional past and future needs and financial losses arising from the negligence, set out as ‘heads of damage’ such as the cost of care, adapted housing and loss of earnings.

Can I claim for a bespoke prosthesis?

One category of damage that is unique to amputation claims is the cost of prosthetic (artificial) limbs. The NHS provides basic prosthetics for those who have suffered limb loss, however the law accepts that the amputee claimant is entitled to recover the reasonable cost of a bespoke prosthesis. Privately funded prosthetics come in a wider range than the NHS is able to provide and can be tailored to the individual’s particular pre-accident interests, including aquatic and sporting limbs. Finding the right prosthesis, which often means a privately funded prosthesis, can make a huge difference to the amputee’s independence and mobility, enabling them to return to work and sporting activities that would not otherwise be possible.

Each step of the process of choosing, fitting and ultimately using a bespoke prosthesis has associated costs which we can include and recover in our clients’ claims, so long as these are reasonable.

Where liability for the injury has been established, we can obtain interim payments to help meet the amputee’s urgent needs and to get their rehabilitation and trial of prosthetics underway as soon as possible, restoring independence, mobility and self-esteem, without them having to wait until the conclusion of the claim.

The sooner we are involved in our client’s journey towards restored mobility, the more thoroughly we can assess their needs and support them through the prosthetics process. Having established that the prosthetic trial has been a success and meets our client’s needs, we can then ensure that provision for ongoing costs, such as for servicing and renewal/replacement is included in the final settlement of the claim.

We also recognise, however, that no matter how good the prosthesis, there will be times when the individual will need additional mobility support. A claim for prosthetic limbs does not replace the claim for additional adapted vehicles and other mobility aids. We work with our medical experts to ensure that our clients’ needs for specialist equipment, such as wheelchairs, now and in the future, are also included in the claim.

If you have suffered amputation as a result of medical negligence or a traumatic injury caused by someone else, contact us by email at claimsadvice@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.

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.

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.

GIRFT Cardiothoracic surgery

Getting It Right First Time (GIRFT) has published its latest report into NHS adult cardiothoracic surgery in England. The GIRFT programme aims to help improve the NHS by identifying variations in practice and procurement, sharing and supporting the implementation of proven best practice with health professionals and hospital managers across the country, thereby improving patient care and saving costs. It does so with funding and support from the Department of Health and is jointly overseen by NHS Improvement and the Royal National Orthopaedic Hospital NHS Trust.

In keeping with previous reports, Cardiothoracic Surgery GIRFT Programme National Specialty Report, makes 20 recommendations which, if implemented could save the NHS up to £52 million a year. The report contains a statement of support from The Society for Cardiothoracic Surgery (SCTS) which also produced a joint response with the Royal College of Surgeons urging the NHS to act upon the recommendations.

The term cardiothoracic surgery relates to surgical treatment of disease in the heart, lungs and major blood vessels in the chest. 7 million people in England have cardiovascular disease which accounts for 27% of all deaths. 28,250 cardiac surgery operations and 69,000 thoracic surgery operations are performed each year. 

Only 31 units in England perform this major, technically demanding surgery in which success depends on highly skilled, multidisciplinary teamwork. Although low-volume compared to many other areas of surgery, cardiothoracic surgery is high cost and often high risk with a measurable mortality rate. Patients needing these sorts of operations have life-threatening diseases and are amongst the most ill that the NHS faces. Since survival rates and clinical outcomes in adult cardiac surgery have been published, they have improved such that the UK’s survival rate for cardiothoracic surgery is currently ranked as one of the best in the world.

The GIRFT cardiothoracic surgery report recommends changes which will improve experience and outcomes for patients which go beyond mortality or survival rates. Delays (which increase risk), cancellations and unnecessarily long stays in hospital will be reduced by a series of measures including:

  • Routine day-of-surgery admission
  • Ring-fencing of ward and ITU beds for elective cardiothoracic surgery
  • Pooling of non-elective cases so that patients are operated on in the next available theatre session with the next available appropriate surgeon
  • Ensuring that every patient is seen by a consultant both pre and post-operatively, seven days a week (to avoid delays in waiting for discharge if no consultant can review at the weekend)

Patients’ risk and outcomes (including risk of stroke and deep sternal wound infection) will be improved by measures including:

  • Ensuring that conditions needing highly specialised treatment, such as aortovascular surgery and mitral valve surgery, are only operated on by surgeons with specialist skills in that condition.
  • Specialist surgeons will operate on higher numbers of cases, as variations in practice,  outcomes and mortality strongly suggest that higher volume is associated with better outcome.
  • Minimum activity requirements for surgeons. 
  • Major trauma centres to have rotas to cover both thoracic and cardiac trauma surgery rather than relying on cardiac surgeons to provide emergency thoracic surgery cover. (There are only 27 cardiothoracic surgeons in England, with 182 cardiac-dedicated surgeons and 92 purely dedicated to thoracic surgery).
  • Centralised and reduced numbers of lung cancer multidisciplinary teams with a thoracic surgeon present on every team.

During their visits the GIRFT team found that because clinicians and providers knew very little about the litigation claims that were being made against them, very few lessons had been learned from claims. The Department of Health has stated its goal to turn the NHS into a learning organisation but unless clinical staff are given information about litigation claims and proper analysis of claims is carried out at local and national levels, opportunities are being missed to improve patient care. GIRFT recommended implementation of their five point plan to reduce litigation costs - including detailed analysis and review of all claims as serious untoward incidents (SUI)  -  to ensure that lessons are learned to save costs and improve patient care.

If you or a family member have suffered serious injury as a result of medical negligence during cardiothoracic surgery call our specialist medical negligence solicitors on 0118 952 7219 or email mednegclaims@boyesturner.com.

Compensation claim settled for £150,000 after hysterectomy causes bowel damage

An individual has received £150,000 to compensate her for the injuries she sustained following an unnecessary sub-total hysterectomy. The surgery was performed after an ovarian cyst was suspected to be malignant.  However, it was later discovered that the cyst was in fact benign and if the doctor had taken the appropriate steps in the circumstances, including a full review of the various ultrasound images, it would have been clear that the risk of the cyst being malignant was less than five per cent.

The individual had a previous medical history of endometriosis and ovarian cysts. Following concerns that a cyst on her ovary was malignant, she was advised by the doctor to undergo a sub-total hysterectomy, even though there was a high risk that she could develop bowel damage and had previously been told to avoid surgery.

It was alleged that the doctor had failed to review the individual’s various ultrasound images, failed to consider the CA125 tumour marker and failed to refer the matter to the multidisciplinary team before advising the individual to undergo surgery.

Following the advice of the doctor, the individual felt re-assured and underwent surgery. Unfortunately, during the surgery her lateral femoral cutaneous nerve and bowel were damaged. As a result, she suffered from peritonitis (an infection of the abdomen lining) and required emergency surgery to repair the bowel and treat the peritonitis. She sadly became infertile after experiencing early menopause and suffered from many other symptoms, including bowel obstruction, severe abdominal pain, poor mobility and a tingling sensation in her legs.

All of her symptoms were considered to be permanent and had a dramatic effect on her daily life. Her husband had to help her to get in and out of bed and help her with personal hygiene. As household chores became impossible, her husband had to resume the role, including cooking, cleaning, laundry and food shopping.

The hospital admitted liability and a settlement was reached in the sum of £150,000. £60,000 was attributable to the individuals pain and suffering which was considered extensive and permanent. £90,000 was attributable to past and future care costs.

Emily Hartland, a solicitor at Boyes Turner comments:

“This is a sad case involving permanent injuries which could have been avoided. Whilst the compensation will never reverse the damage caused, the money will help the individual and her husband to pay for any future care needs. ”

New recommendations - obese patients with diabetes to be offered weight loss surgery

Recommendations have recently been published for patients who are obese (with a BMI of 35 and over) with recent onset of type 2 diabetes to be offered an assessment for weight loss surgery.  The recommendations highlight the need to identify and manage the obesity as well as the diabetes. 

Additionally, those patients who have a BMI of between 30 and 34.9 with recent onset type 2 diabetes should potentially also be offered an assessment for weight loss surgery.

The aim is that these patients will have more control over their diabetes, which may help reduce the medication they require.  It must be recognised that weight loss surgery requires long term management in terms of diet and exercise in order to manage diabetes.

If the diabetes is managed successfully, it is reported that patients will be less likely to have diabetes-related illnesses such as heart disease, stroke, nerve damage, eye damage and kidney disease.  Despite the potential benefits of weight loss surgery, it also carries serious risk of complications and should be carefully considered.

The outcome of the consultation is awaited.

The current criteria for weight loss surgery is set out here

Sita Soni of the medical negligence team at Boyes Turner comments:

“that with the increasing availability of weight loss surgery and more operations being performed, medical negligence claims in relation to this type of surgery have also seen a rise, as previously reported by the Medical Defence Union. Unfortunately each type of weight loss surgery carries a high risk of complications. Some complications are recognised and cannot be avoided, but other errors would be considered negligent and which can result in a weight loss surgery compensation claim.”

Six figure settlement after skin reduction surgery complications

Nicola Woolley, a 45 year old lady, who underwent a successful gastric bypass operation in 2007, has been left with permanent skin disfigurement and lifelong pain after an alleged negligent procedure to remove excess skin. It is reported that the surgeons removed too much skin causing various problems.

Ms Woolley who was 26 stone before the gastric bypass and lost 11 stone after the surgery, underwent a tummy tuck to remove excess folds around her waist and stomach in 2009, but subsequently developed serious blistering and significant pain.  She was diagnosed with epidermolysis (a skin disorder causing the skin to become fragile and can result in serious blistering).

Ms Woolley underwent 12 further procedures including skin grafts and fluid drainage in attempts to improve matters but doctors then told her there was nothing further they could do.

Ms Woolley instructed legal advisers to investigate a medical negligence claim into the care she received from the hospital.  The hospital did not admit the care was inappropriate in any way but settled the case for an undisclosed six figure sum.

Ms Woolley is now left in permanent pain in her lower back and buttocks, whether sitting down or standing as well as scarring.  It is reported by the legal advisers that the compensation will help Ms Woolley adapt her house, bring in professional carers to assist with her daily routine, fund pain management therapy as well as emotional support. It is also said that it is unlikely she will be able to work again.

Sita Soni, solicitor with the Boyes Turner medical negligence team, comments:

“It is devastating for this lady and her family that she underwent the weight loss procedure (also known as bariatric surgery) for better quality of life, but that surgical complications of the excess skin removal has meant that she is now dependent on others and will experience lifelong pain and discomfort.  Hopefully the compensation will go some way in overcoming some of the difficulties she faces”.

  • Page 1 of 4

The service was personal, professional and considered. I was treated so kindly and in the end I knew that not only had I found the right organisation but also the right person.

Boyes Turner client

Get in touch

Please get in touch 0800 124 4845

Or we are happy to call you back at a time that suits you

Office open Mon - Fri: 08:30 - 18:00