As part of the NHS Litigation Authority’s objective to improve patient safety and reduce harm, they have undertaken a review of three key areas of medical practice, which tend to generate high volume or high value claims:
- general surgery; and
- accident and emergency.
Here, we look at general surgical and A&E claims to see why these areas lead to claims for clinical negligence and whether any lessons can be learnt to reduce harm.
General surgical claims
One of the difficulties with general surgery is that, unlike some other disciplines, such as maternity (which has a single process, well-established stages, effective monitoring and well-developed pathways), the remit is extensive. General surgeons are faced with anything from cancers to Crohn’s Disease, to pelvic floor problems or prolapse.
Additional areas include appendicitis, intestinal obstructions, gall stones, pancreatitis and trauma. With all these possibilities, the pathways are complicated and numerous, and it is not always straightforward to identify the clinical diagnosis at the outset or the extent and severity of the patient’s condition.
General surgical complications can occur either non-operatively, in the intra-operative stages, or post-operatively. Therefore at all times clinicians must be aware of possible difficulties and how to act on the same:
- Non-operative difficulties
One of the most common areas giving rise to claims is where there has been a delay in diagnosing a patient’s condition. This can either occur at a primary level, i.e. by the GP, or at hospital, often because a diagnostic pathway is not completed and/or there has been a missed lesion (during colonoscopy for example).
Diagnostic delay often occurs where a patient has an inflammatory bowel disease, yet despite repeated presentations to their GP or to A&E, the severity of the condition is not appreciated. While it is accepted that the diagnosis may not necessarily be sinister, it could be a form of Colitis, which needs to be treated promptly.
Part of the difficulty is that with Colitis, there needs to be a mechanism of review and early referral to a gastroenterologist. If a patient presents multiple times to a range of organisations (their GP, an out of hours service, walk in centre and/or to A&E), there is no continuity of care and the condition may go undiagnosed for some time.
Diagnostic delays can also commonly occur when a patient complains of an acute abdomen (pain in the abdomen that usually comes on suddenly and is so severe that patients may have to go to hospital). This is because, while it can signal a variety of more serious conditions, some of which require immediate medical care or surgery, it could also be something which is relatively innocuous. Clinicians have to decide on the severity of a patient’s condition, often based solely on their presentation and any blood test results, where CT scanning does not appear to be indicated.
- Intra-operative complications
Problems can arise where there is a perforation or injury to an organ during the course of surgery, often caused inadvertently during laparoscopic procedures.
Intra-operative injuries are not always indicative of a failure to provide an appropriate standard of care; however claims often focus on the failure to identify and treat the complication at the time it occurs or post-operatively (see below).
- Post-operative problems
Post-operative claims often arise where there has been a delay in recognising an anastomotic leak, internal bleed or peritonitis for example. The key is to identify any potential symptoms which may not be in-keeping with the predicted outcome and to intervene as soon as possible. This can be difficult if a patient has symptoms which are masked reason of by post-operative pain relief.
According to the Department of Health website attendances at the A&E department seem to be increasing year on year. The difficulty with A&E attendances is that there is almost a limitless range of presentations which (combined with the pressures of time and staffing levels) means that serious conditions are often missed.
The stages of the emergency department processes are numerous and there are ample opportunities for clinical error or oversight to occur; for example when:
- a patient is triaged;
- their observations are taken;
- they are examined by a doctor;
- investigations are undertaken;
- a conclusion is reached;
- treatment is commenced; and
- referral and follow up is provided.
However, there are two areas that generate either high value or high volume claims: scaphoid injuries and Cauda Equina cases.
- Scaphoid Injuries
It is very common to miss a scaphoid fracture, due to the numerous mechanisms by which a scaphoid injury can be caused (although it is usually caused by a fall onto an outstretched hand), the incorrect anatomical area being examined or failure to x-ray. A further difficulty arises due to the fact that it is thought that about 5-10% of scaphoid fractures are not visible on initial films. Ultimately patients can have a very poor prognosis if appropriate management is not undertaken.
However, it should be an injury that is relatively straightforward to diagnose if the scaphoid is examined for tenderness, appropriate x-rays are requested (including scaphoid views), and routine follow up is arranged, when a scaphoid fracture can be confirmed or ruled out.
- Cauda Equina Syndrome
The symptoms of Cauda Equina Syndrome include:
- acute lower back pain;
- radiation of pain to the legs;
- alteration of perennial sensation; and
- alteration of bladder and bowel habits.
It is now thought that there is a window of around 24 to 48 hours from the onset of urinary and/or bowel dysfunction for treatment to be undertaken in order to ensure a better outcome (although the likelihood of recovery is still an area of controversy). For this reason it is crucial that medical personnel within the A&E department are acutely aware of the early warning signs and symptoms of the condition as well as the need for urgent investigation and surgery if necessary. Good medical records outlining the symptoms and when they started, are crucial, as well as advising patients to seek follow up treatment if any ‘red flag’ symptoms develop.
Increasing patient safety and reducing harm remains a key focus for the NHS Litigation Authority.
It is not always an easy thing to do, especially in areas such as general surgery and A&E, where conditions are numerous and clear pathways do not always exist. However, by focusing on the areas set out above, where the likelihood of clinical negligence claims is increased, and by identifying the potential pitfalls, hopefully lessons can be learnt and a higher standard of care provided to patients, with a consequential reduction in claims.