Informed is forewarned

01 January 2008

Mrs L, a 71-year-old woman, attended an orthopaedic surgeon, Mr D, complaining of pain in her left hip and leg. Investigations including an MRI scan confirmed a L4/L5 disc protrusion compressing the L5 nerve root generating nerve pain.

Mr D recommended surgical decompression and the patient was admitted to hospital. The surgeon briefed Mrs L on the procedure but did not think it necessary to discuss the very slight risk of deep infection (spondylo-discitis/osteomyelitis) attendant to the procedure. The surgery went well and Mrs L made a good initial recovery.

A month later Mrs L presented to her GP with severe back pain and was referred again to Mr D. Examination and further MRI scanning revealed no significant abnormality and blood tests were normal. But the pain persisted and re-exploration was thought to be indicted.

A second operation revealed loose disc material and tissue fibrosis but no obvious signs of infection. The loose disc material was removed for bacteriological examination but unfortunately was mistakenly put into formalin by a member of staff as for histological examination and then subsequently discarded.

Mrs L was discharged home but again suffered 'considerable' back pain. A second opinion was sought and a further MRI scan confirmed post-operative discitis. This was treated with antibiotics but took considerable time to clear and caused Mrs L a great degree of pain and immobility.

A claim of clinical negligence was subsequently received from Mrs L's solicitors.

Analysis and outcome

Expert opinion found Mr D at fault in a number of respects. In briefing the patient the surgeon should have made Mrs L aware of the slight risk (0.2 - 0.8 per cent) of deep post-operative infection. Consent to treatment is not valid unless 'informed' and this includes possible complications and side-effects.

He was also found at fault for not recognising that the patient was making poor progress and thus suspecting and confirming the diagnosis of discitis much earlier. This would likely have saved Mrs L a long period of undue suffering and possibly a second operative procedure. The mishandling of the operative specimen also contributed to further delay in diagnosis.

The MDDUS deemed the case indefensible and the claim was settled on an economic basis.

Key points

• "Informed" consent is a basic requirement for all medical procedures.
• Ensure correct specimens are taken and correctly sent to laboratory for appropriate examination.
• If patients are not progressing as expected consider an early second opinion!

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