Five months of intensive dieting had left Mrs H 3 stones lighter but still unhappy with the appearance of her abdomen. So she attended a plastic surgery clinic for cosmetic abdominoplasty. Dr R, as was his custom, discussed the procedure with Mrs H but unfortunately failed to record in the notes exactly what was said in the consultation.
The operation went well but Mrs H developed postoperative flap necrosis. Conservative treatment failed and another operation was required to remove the necrotic tissue and apply a skin graft, with resultant scarring.
A solicitor's letter was later received by the private clinic alleging clinical negligence. Mrs H claimed that Dr R had failed to warn her of possible complications and had offered no preoperative advice on smoking cessation - smoking being a known risk factor for postoperative necrosis in abdominoplasty.
Analysis and outcome
The lack of an adequate contemporaneous clinical record meant Dr R was unable to offer documentary proof that Mrs H had, in fact, been informed of possible post operative risks including flap necrosis and counselled to stop smoking prior to the operative procedure. The case was settled for £20,000 and after much anguish to both doctor and patient.
- Pre-operative advice regarding possible complications must be given.
- Record the advice given in case of a future dispute.