A 50-year-old accountant, Mrs A, developed altered bowel habit and rectal bleeding. She saw consultant colorectal surgeon Mr C, who found large prolapsing haemorrhoids and recommended a haemorrhoidectomy and colonoscopy. Mr C removed a 5mm polyp in the caecum with a snare and then went on to perform a haemorrhoidectomy. Both procedures were described as uneventful and Mrs A was stable throughout the anaesthetic.
A few hours later, after the operation, Mr C noted Mrs A was well and ready for discharge. She subsequently developed minor rectal bleeding and abdominal discomfort, and was kept in overnight. The following morning, her routine blood tests were normal and her observation chart had been unremarkable, but the abdominal pain persisted.
A chest x-ray revealed bilateral sub-diaphragmatic free gas. Mr C prescribed broad-spectrum antibiotics, intravenous fluids and kept Mrs A ‘nil by mouth’. An urgent CT scan confirmed an extensive pneumo-peritoneum but no signs of any fluid collection.
Mr C examined Mrs A and found a “completely soft abdomen with no peritonism and normal bowel sounds”. He explained that the perforation had probably occurred at the polypectomy site, but appeared to have sealed as Mrs A was well and the CT scan had revealed no fluid collection.
Mr C recommended conservative management with surgical intervention only in the event of septic complications. Over the next few days, Mrs A remained well, was apyrexial and had normal inflammatory markers. She commenced oral fluids and was discharged home with seven days of antibiotics.
Mr C reviewed her at the end of the week and noted “she continued to feel well, clinical examination was normal and the site of her haemorrhoidectomy was healing nicely”. The pathology report of the polyp revealed a completely excised low grade tubulo-villous adenoma and Mr C explained the need for surveillance colonoscopy.
Two weeks later Mrs A contacted Mr C complaining of night sweats, abdominal pain and vomiting. He saw her immediately and arranged an ultrasound scan, which revealed a large pelvic abscess. Mr C organised her admission to another hospital for radiologically guided drainage of the abscess, but this proved unsuccessful. Her condition deteriorated and Mr B, the consultant surgeon oncall at this hospital, undertook an emergency laparotomy to drain the abscess and perform a defunctioning ileostomy.
Mrs A had a stormy postoperative recovery, initially requiring ITU support, and spent three weeks in hospital. Mr B subsequently reversed her ileostomy but Mrs A developed problems with an incisional hernia, requiring several attempts at repair. She also needed psychological support for post-traumatic stress disorder, resulting in prolonged absences from work.
Two years later, Mrs A brought negligence proceedings against Mr C. It was claimed that Mr C should have acted sooner by performing an x-ray and CT scan on the evening when Mrs A initially developed pain. It was also alleged that Mr C had selected inappropriate antibiotics and had discharged her too early, allowing the development of her abscess. It was suggested that these acts of negligence had delayed appropriate surgical treatment and directly led to all Mrs A’s subsequent complications.
Expert opinion did not substantiate any of these claims. It was agreed that non-operative management for perforations after colonoscopy was an acceptable practice if the patient was stable, exhibited no signs of sepsis and the perforation appeared to have sealed.
The CT result, together with the carefully-documented clinical findings, nursing charts, and absence of a rise in the patient’s inflammatory markers over several days, all supported this approach. Microbiology experts agreed that the antibiotics prescribed were appropriate and the length of administration sufficient. Mr C was also able to produce audit evidence of his colonoscopy practice, demonstrating a high volume (400 per annum) with a very low complication rate.
Whilst the time and stress involved in legal claims can be considerable, it is important to remember that many cases are defended successfully (and often long before court proceedings) because Drs simply practice good medicine. Hindsight alone is not actionable.