Dr Rob Hendry - Medical Protection Society

20
CASE REPORTS GENERAL PRACTICE DIAGNOSIS/INTERVENTION AND MANAGEMENT
UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk
Cuts and bruises
Mrs S was a 65-yearold
lady who had
been suffering with
stress incontinence and the
discomfort of prolapse. She
had a busy life looking after
her three grandchildren and
was finding her symptoms
were interfering with this.
She was admitted by her
gynaecologist, Mrs V, for
a vaginal hysterectomy,
anterior and posterior vaginal
repair and a colpopexy.
The procedure appeared
uneventful and Mrs V
explained to Mrs S that the
surgery should relieve her of
her symptoms successfully.
The next day, one of the
junior surgical team noticed
that Mrs S had a large bruise
on her right buttock. This
was discussed with the
team and it was thought
that this was caused due
to her position on the
operating table. Mrs S was
reassured by this explanation
and was discharged from
hospital five days later.
Three days later, Mrs S
began to feel unwell. She
felt feverish and had rigors
that frightened her. She
also developed diarrhoea
and some yellow vaginal
discharge. She felt so
unwell that she requested
a home visit from Dr W,
her GP. There was very
minimal documentation in
Dr W’s notes about this visit
except that he started some
antibiotics and that he had
noticed a bruise extending
from her buttock to her knee.
In particular, there was no
documentation of her vital
signs such as temperature,
pulse or blood pressure and
no written evidence of an
abdominal examination.
Over the next two weeks,
Mrs S became increasingly
concerned. She remained
feverish and was finding it
harder to walk because of
pain in her right buttock and
abdomen and swelling in her
right leg. By the second week
she was hardly able to walk
at all and felt very unwell.
She was visited at home by
three different GPs from her
practice. Each of the GPs
noted the bruise that seemed
to be extending down her leg
but, again, did not document
much else about her
examination. The antibiotics
were changed three times.
When the bruising and
swelling in her leg continued
to worsen, one of the GPs
discussed her case with the
on-call gynaecologist over
the phone. The gynaecologist
thought Mrs S may have a
DVT and suggested she go
to the emergency department
(ED) rather than to the
gynaecology ward. When
Mrs S arrived, she went to
the medical assessment unit.
The medics assessed her,
but the on-call gynaecologist
did not. She spent two days
in hospital and, although
an ultrasound scan failed to
show a DVT, she became
increasingly unwell.
On the second day her
temperature was spiking,
her pulse was raised and her
BP was running low. She
was referred to the surgical
ward, where she underwent
an urgent CT scan,
followed by a laparotomy.
An extensive necrotising
infection between the sacrum
and rectum, extending
into the right ischiorectal
fossa, and multiple abscess
tracks were found. Mrs S
spent three months on the
surgical ward undergoing
extensive surgical treatment,
including a loop sigmoid
colostomy and recurrent
debridement of the leg.
Mrs S was traumatised
by her long stay in hospital,
the discomfort of all the
surgery and with having to
come to terms with having a
colostomy. She made a claim
against Mrs V and the three
GPs who visited her at home.
EXPERT OPINION
Experts agreed that Mrs V
did not take enough care,
by performing a rectal
examination, to ensure that
the rectum had not been
perforated by a suture
during the posterior repair.
LEARNING POINTS
The GPs were criticised
on several points. Firstly,
it was felt that they had
failed to consider a
serious bacterial infection
relating to Mrs S’s recent
surgery. There was no
documentation of her
vital signs to assess
the fever and severity
of her condition.
Secondly, it was felt that
they failed to adequately
examine the bruising and
swelling to the right buttock
and leg. Lastly, it was felt
that they had failed to
arrange admission and
investigation earlier. The
on-call gynaecologist was
also criticised for failing
to assess the patient as
requested and therefore
delaying her care for 48
hours. The claim was
settled for a substantial
sum, divided between the
hospital and the GPs.
AF
■ A diagnosis made by colleagues can always be
challenged in the face of continuing symptoms. The
three different GPs who saw Mrs S simply relied
on each other’s opinion rather than seeking a new
diagnosis.
■ The GPs were criticised not for failing to diagnose
her, but for failing to realise how ill she was and
organise a timely admission. There was no
documentation of her vital signs that could have
illustrated the severity of her illness.
■ Recent past medical history is likely to be relevant. It
should be documented and considered.
■ When there are post-surgical complications, the
standard of aftercare is extremely important.
■ This case highlights the importance of acting when
a patient is deteriorating or failing to improve despite
the working diagnosis and treatment.
DR P. MARAZZI / SCIENCE PHOTO LIBRARY