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www.medicalprotection.org Casebook Promoting patient safety

DiagnosingDiagnosing acuteacute headachesheadaches

TheThe risingrising costcost ofof injuriesinjuries

PLUS: Our usual mix of case reports,letters and news

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www.mps.org.uk The MPS website has improved. It now features: A search engine which enables you to find the information you want more quickly, whether on a particular specialty (e.g. anaesthesia), a precise issue (e.g. consent), or a specific procedure (e.g. cholecystectomy). It will quickly find all the related articles, case reports and news on the website. Case reports and articles – more of these are now on the website, and more will be added over the coming months. News service – we have improved the news that we offer, providing the latest relevant information on the legal issues that affect your practice. Casebook – the latest edition of Casebook is on the website complete with many extras, including links to further information, guidelines and references.

Take a look at the changes: www.mps.org.uk Casebook Extra More links and background reading are now available on the MPS website. 69651_UK_MED_P 30/7/03 12:01 PM Page 3

Contents

Editorial board Dr Jane Cowan ARTICLES Dr Richard Dempster Dr Paul Farrugia Cases dealt with by MPS help highlight the potential pitfalls when treating patients 8–14 Dr Lyn Griffiths Dr Tim Hegan with acute headaches. Dr Graham Howarth Dr Janet Page How the United States compensation culture has infected litigation 15–16 Dr Gerard Panting Dr Ian Woods Editor in Chief CASE REPORTS 17–25 Dr Gerard Panting Editor TARDY SURGICAL INTERVENTION POST-OPERATIVE HYPOTENSION Sandy Anthony FORGOTTEN SPECIALIST REFERRAL INFUSION RISKS Staff writers Jonathan Haslam SHOULDERING RESPONSIBILITY MAYBE MALARIA? Sean Kavanagh INSPECT BEFORE YOU INJECT TREAT PIGMENTED SKIN LESIONS WITH CARE Annmarie McTigue Proof reader THE DOWNSIDE OF LUSCIOUS LIPS DUTY TO WARN Pippa Vine Design and Production A TIGHT SITUATION Cambridge Publishers Ltd Print and Distribution Co-ordinator NOTICEBOARD 4–7 Philip Walker Printers Frank Peters Limited, BOOK REVIEW 25 Kendal, UK Please address Promoting child health in primary care correspondence to: The Editor, Medical Protection Society, LETTERS 26 Granary Wharf House, Leeds LS11 5PY, UK. Smooth v textured breast implants; Corneal damage and anaesthesia; [email protected] MPS Casebook is Lost IUCDs;Antibiotic prophylaxis published by: Medical Protection Society, Granary Wharf House, CONTACTS 27 Leeds LS11 5PY, UK. What MPS can do for you, including useful contact details for medico-legal advice, websites; and how Tel: 0845 605 4000 Fax: 0113 241 0500 to order publications.

The suggestion that, within a new NHS Redress changing the current indemnity system in primary Second opinion Scheme, claims below £30,000 should be assessed on a care. new basis of ‘substandard care’rather than the The report also recommends introducing a duty of Dr Gerard Panting existing Bolam test is flawed and, frankly, confusing. candour. MPS has long advised doctors and dentists Communications and The Bolam test is the standard by which courts in who have made a mistake to establish the full facts, Policy Director England and Wales assess doctors’clinical practice. In provide an explanation, apologise to the patient and essence, a doctor is not deemed negligent if he/she is consider what they might do to prevent similar errors Sir Liam Donaldson’s acting in accordance with accepted medical practice. occurring in future. To meet the proposed duty of long-awaited report on This already establishes the required standard of care, candour, the doctor or dentist first has to be aware reforming clinical so it is difficult to see where the new notion of that they have done something wrong. In medicine negligence litigation in ‘substandard care’will sit in relation to it.Will it be a and dentistry, mistakes are not always immediately England (Making Amends) has now been published. higher or a lower standard? To accept a lower apparent and it can be the case that the practitioner is As a member of that working party, I am delighted to standard of care is inconceivable, but if the standard unaware that anything is amiss. In many cases, there see that many of MPS’s recommendations have been were to be set higher, all doctors providing care in is a fine line between negligent and non-negligent included but, as the CMO himself has pointed out, it accordance with accepted medical practice would be care that can be hard to discern, particularly for those has been impossible to reach a consensus and it is no condemned as negligent. who are involved in providing care to that patient. surprise to see a number of proposals which we view In the first instance, the Redress Scheme would MPS’s full initial response can be viewed at as inappropriate. only apply to NHS hospitals and not to primary care, www.mps.org.uk Of the 19 recommendations, MPS fully supports but, subject to evaluation after a period of time, it is Making Amends is a consultation paper which will the vast majority. In particular, we are pleased to see proposed that consideration should be given to lead to the publication of a White Paper towards the the proposal for a no-fault compensation system for extending the NHS Redress Scheme to primary care. end of 2003.Any legislation that follows is unlikely to patients suffering from severe perinatal injury – Claims arising from primary care are very come into force before 2006. something MPS has campaigned for since 1990. MPS different to those in the NHS hospital sector. Primary has also pressed for the establishment of specialist care is a sector in which MPS has unrivalled expertise NHS centres to care for the profoundly injured in as well as the confidence of healthcare professionals place of attempting to meet their needs at home on a working within it. Given our record of speedy private basis. resolution of low-value claims, there is no case for Opinions expressed herein are those of the authors. Pictures should not be relied upon as accurate representations of clinical situations. ©The Medical Protection Society Limited 2003 All rights are reserved. ISSN 1366 4409

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The largest collection A mixed bag support to make decisions. They of reform may need help because of learning of free CME just got better difficulty, brain injury, dementia, MPS has given qualified support to mental health problems or any other ‘Extremely interesting and it is actually fun and interesting, the Chief Medical Officer’s report illness or disability that affects the good way of doing CME’ described by one GP as ‘Very on clinical negligence reform, person’s mental capacity. Doctors.net.uk and MPS imaginative – it makes learning easy, published on 30 June. Making Booklets have been produced for collaboration gives you more choice fun and effective’. These are not Amends is a consultation document various groups, including legal Key features: words frequently associated with recommending a scheme that will practitioners, social care • Free to all UK doctors; the endless trawling of journal offer a package of apologies, care professionals and people with • Simple, powerful way of learning; articles or hours spent at the local and compensation to injured learning disabilities. • Bite-sized chunks of CME; postgraduate centre that used to be patients as an alternative to The booklet for health professionals • No computer knowledge necessary; the only way of keeping your litigation. It includes our long- includes guidance on a range of • Huge range of subjects; knowledge updated. Online standing recommendation for the issues, including • Case-based learning – based on learning is based on challenging, creation of a no-fault • Defining and assessing mental real patients; and real-life case scenarios, complete compensation scheme for children capacity; • One click to add to your PDP or with ECGs, x-rays or clinical brain damaged at birth. • Deciding on a patient’s best appraisal folder. findings.You have to make the The report recommends setting interests; Think online learning is a thing of decisions and you instantly see the up an NHS Redress Scheme that • When to make an application to the future, or only for those who results of your actions. would investigate medical mishaps, the High Court; and like computers? Think again! The arrange remedial treatment, • Advance statements. fastest growing area of continuing How do I start? rehabilitation and care for the It explains the current legal position medical education for doctors Simply go to www.Doctors.net.uk, patient and provide them with full and lists sources of further guidance (CME) is that done through the click on ‘Education’ and select the explanations of what went wrong, and relevant organisations. internet or online – over 10% of UK module that meets your needs. You with an apology. Financial It does not include guidance for doctors have already used online will find a huge range of subjects compensation would also be an children and young people or the CME, with a staggering 93% saying covered, whatever your specialty. option. treatment of patients for mental they intend to do so in the next year. In addition to modules of interest A new national body would take disorder under the Mental Health So just why is this way of keeping to all doctors, there are special over the work of the NHS Litigation Act. The information relates only to your knowledge up to date so courses for GPs, SHOs, physicians, Authority and would oversee the England and Wales. popular and how can you use psychiatrists, nephrologists and NHS Redress Scheme and manage A PDF copy of the guidance is on online learning to get CME points anaesthetists, with more learning the financial compensation element the Department for Constitutional or as part of your revalidation? being added every month. at a national level. Affairs website: Launching in August is a brand The report contains many other www.lcd.gov.uk/family/ Simple to use new collaboration between MPS recommendations that would have mi/mibooklets/guide3.pdf. Well the good news is that it is very and Doctors.net.uk. Designed a significant impact on healthcare simple – indeed, if you can use specifically for house officers: the paractitioners. Among them is the Claims eating Google you can use Doctors.net.uk MPS Foundation Course meets the proposal that reporting errors to online learning. Designed by needs of new graduates but it may patients should be mandatory – a into budget doctors, for doctors, all you need is prove testing for those of us who so-called ‘duty of candour’.We have The NHS in Wales paid out £46.2 access to the internet – whether graduated more than a few years some reservations about this million for clinical negligence claims through NHSnet at work or a ago! proposal as it assumes that one is in 2001/02 – four times as much as normal telephone line at home – aware of errors at the time, which is the previous year. As a result, the and a comfortable chair. Indeed, Any questions? not necessarily the case. service fell £16 million into debt one of the most popular features of All Doctors.net.uk CME is View the full report at from being £23.7 million in the online learning is the ‘Martini completely free of charge to you as www.doh.gov.uk/makingamends black the previous year. This debt factor’ – you can choose to do your a UK doctor. Simply go to The MPS response can be viewed at could rise to £44 million for learning anytime, anyplace, www.Doctors.net.uk for more www.mps.org.uk 2002/03, which could swallow up anywhere. What this means is that details and to start using your the extra funds created by the 1p you can start a course at work and personal learning library. Capacity to consent increase in National Insurance. choose to finish it at home – see Alternatively, phone the free The Association of Welsh more of the family and collect CME helpdesk on 01235 828401; they The Department for Constitutional Community Health Councils said points from the comfort of your will be happy to answer any Affairs (previously the Lord the NHS needed to raise standards armchair! questions you might have. Chancellor’s Department) has in patient care and give medical staff www.Doctors.net.uk – published new guidance on consent. sufficient time to address patients’ Life and death decisions by doctors for doctors Making Decisions: Helping People concerns and questions to cut down (virtually!) Neil Bacon MRCP who have Difficulty Deciding for on the margin of error. The second reason for the Founder and CEO, Doctors.net.uk Themselves offers advice on the care www.makeashorterlink.com/ popularity of online learning is that and treatment of adults who need ?R371431D4

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if the software allows large screen August deadline looms fonts, contrasting colours and flashing messages. Pop-up messages All NHS bodies, among them response. This comes into force can be found on the MPS should be reviewed on an ongoing NHS GPs, dentists, pharmacists in January 2005. website at www.mps.org.uk. basis and any that are no longer and opticians, must submit a Producing a Publication Simply completing a model applicable should be deleted. publication scheme to the Scheme scheme does not fulfil your www.rcgp.org.uk/rcgp/quality_ Information Commissioner by 31 There are two ways of producing a obligations under the Act. You unit/docs/1.204ISHissue2v15.pdf August. publication scheme – either by must then make the publication ISMP Medication Safety Alert! 2 (7) The Freedom of Information Act producing a bespoke scheme or by scheme available (for example on 2000 gives the public a general using a pre-approved ‘model’ your website if you have one). You right of access to all types of version. must also publish information as information and it imposes two If you produce a bespoke promised in your publication main responsibilities on public publication scheme you will need scheme, and you will need to authorities: to have it approved by the ensure that the scheme is kept up • To produce a publication scheme Information Commissioner. If you to date, for example as – a guide to the information the use a model scheme you will only information changes or new organisation holds that is need to send a declaration form to publications are published. available to the public. The the Information Commissioner, The NHS Freedom of Information scheme must be submitted to the confirming that you have website – www.foi.nhs.uk – has Information Commissioner for produced a publication scheme. some useful information on approval by 31 August 2003 and The BMA and the NHS Freedom model publication schemes. More be in place by 31 October 2003. of Information Project Board have information on bespoke • To respond to individual produced a model scheme for publication schemes can be found requests for information – either GPs. More details on the on the Information by referring to the publication information you will need to Commissioner’s website – Free help with scheme or by providing a specific include in this publication scheme www.dataprotection.gov.uk revalidation

Revalidation is a major change to the GP errors – more negligence claims, which currently another drug; these included way that doctors in the UK are research needed cost £400 million a year. Clobetasol and Clobetasone, and regulated. Every five years you will http://fampract.oupjournals.org/cgi/ Lamisil and Lamictal. The college need to prove that you are fit to A government study has found that content/abstract/20/3/231 suggests including tick boxes in practise. Although this won’t begin as many as 2.8 million GP computer software for the doctor to until 2005 at the earliest, you need to consultations every year result in a confirm his/her choice of drug or to start collecting evidence for medical error – one in every 120. introduce a permanent reminder revalidation now. Researchers at Manchester that the drug chosen has a similar Revalidation need not be a University examined 15 studies on name to another. worrying process. For the most part medical errors in primary care, Meanwhile, the American it simply means putting documents including research by the Medical Institute for Safe Medication that you already have into a folder to Protection Society, which found that Practices (ISMP) has issued a build your body of evidence. 63% of all medical legal action warning about the risk in having too However, there are a couple of stemmed from GPs’ errors in many alerts built into prescribing important points that you should investigation and treatment. The software. They report that ‘the sheer consider: study also suggests that over 60% of number of warnings that appear on • You need to be organised. errors could have been prevented. the screen during order entry can be • You need to start now. However, the report admits the true overwhelming and slow the process. To help you begin compiling the frequency and nature of medical Tackling prescription In many cases, clinically insignificant evidence you need, MPS has error is complicated by the different warnings are as likely to appear as produced a free set of A4 dividers. definitions and methods used in the errors those that are vital.’ They outline the information you studies, and more research is needed The RCGP has called for the The ISMP suggests that need to collect in each section, to discover the real picture. National Patient Safety Agency to prescribers regularly refine and provide some ideas on how to find The government hopes the work more closely with national update their system’s list of the information and, of course, National Patient Safety Agency’s computer suppliers to curb the significant alerts.‘Use internal and neatly divide your revalidation adverse incident reporting scheme, number of prescribing errors. In the external information on possible folder into logical sections. which will encourage doctors to latest issue of In Safer Hands,the serious drug interactions, errors, Please call MPS Publications report errors and near-misses RCGP published a list of drugs most duplications and so on, to guide this on 0113 241 0354 or e-mail anonymously, will improve safety commonly prescribed incorrectly process.’It also recommends making [email protected] across the NHS and reduce because they have a similar name to significant alerts as visible as possible for your copy. Continued on page 6

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Continued from page 5 Recognising of NHS patient involvement, which competent adult suffering from a includes patients’ forums and the terminal disease or incurable physical child abuse Patient Advice and Liaison Service illness could ask for medical assistance The Northern Ireland branches of the (PALS). But, in June, the Commission to die. Karen Sanders, chair of the NSPCC and Barnardo’s have said for Patient and Public Involvement in Royal College of Nursing’s ethics A&E staff still need more training in Healthcare admitted it had yet to forum, has given her support to the diagnosing, detecting and reporting finalise arrangement for training its bill, but there is strong opposition child abuse. Their report, Child staff. Although the forums will from disabled rights groups and Protection is No Accident, was Patients don’t always operate a basic service from Catholic bishops, who fear a change in produced with staff from A&E December, its staff will not be fully the law would put pressure on disabled departments in Northern Ireland and understand trained until Spring 2004. Health people to seek an assisted suicide. the Department of Health, Social Doctors are being urged to structure minister David Lammy responded to http://news.bbc.co.uk/1/hi/health/ Services and Public Safety. It said that, the advice they give to patients, as this news by extending the CHCs 2968078.stm although there was plenty of good most people remember a ‘strikingly until December to facilitate a smooth child protection practice in A&E small’ amount of the information handover between the two systems. Retention of organs departments, staff were still uncertain doctors tell them. In the May Journal www.health-news.co.uk/ about accessing the Child Protection of the Royal Society of Medicine,Dr showstory.asp?id=112960 without consent – a Register and knowing the best people Roy Kessels claimed most patients criminal offence? from whom to seek advice. It forgot up to 80% of what they were Certifying death and recommended staff induction and advised as soon as they left the clinic. HM Inspector of Anatomy, Sir Jeremy training in child protection, as well as This poses major risks to patient the coroner service Metters, has said taking organs without full guidance for frontline A&E safety, especially with the trend The Luce Report has called for radical consent should be made a criminal employees in identifying child abuse. towards shorter hospital stays and reforms to the death certification offence. This follows his investigation http://www.nspcc.org.uk/html/home/ more outpatient care. process to protect patients following of the Cyril Isaacs case, where Mr informationresources/aandedetect Research by the American Medical the case of serial killer Harold Isaac’s brain was retained without the childabuse.htm Association goes one step further, Shipman. The Independent Review consent of his relatives following his linking the ‘health literacy’ of patients of Coroner Services was led by Tom suicide in 1987.As strict Jews, they to how much they might understand Luce and took two years to complete. would have refused permission. The doctors’ advice or medication It makes 122 proposals to improve report emphasised that ‘complete directions. It found that almost 25% efficiency and bolster public openness’was needed from everybody of all adult Americans read at or confidence, including a call for all GP- involved in postmortem examinations below 5th grade (8/9 years) age level, certified deaths that do not go to a to restore public confidence. while medical information leaflets are coroner to be countersigned by a The Royal College of Pathologists written at 10th grade age reading level second doctor, who will report to a stressed that retaining brain tissue or above. It also found that more than new Statutory Medical Assessor from postmortems was vital for 40% of patients with chronic illness (SMA). These SMAs will advise research, but that its own guidelines NHS workers prone were functionally illiterate and only coroners on medical issues and on organ retention, published in half of patients take their medication oversee death certification. The report March 2000, had helped to remedy to accidents as directed. So those with the greatest also recommends a more flexible confusion over this issue of consent. A National Audit Office report says healthcare needs may have the least death investigation system, offering The full report, conclusions and staff-related accidents in UK ability to comprehend the bereaved relatives the right to request recommendations can be viewed at hospitals are increasing. In 2000, the information necessary for their a review of certain decisions made by www.doh.gov.uk/cmo/isaacsreport Department of Health’s Working successful treatment. the coroner. Together initiative aimed to cut www.roysocmed.ac.uk/ The full report can be seen at Letter imperfect incidents like needlestick injuries new/pr132.htm www.official-documents.co.uk/document/ and falls by 20% by 2001. But the http://jama.ama-assn.org/ cm58/5831/5831.pdf Research has shown there are often NAO’s report showed the total cgi/content/abstract/281/6/552 critical flaws in computer-generated number of accidents had increased Euthanasia bill gets letters sent to GPs from A&E by 24%, with only 23% of NHS CHCs stay until departments after they have treated trusts meeting the reduction target. second reading patients. Researchers found incomplete The findings and recommendations December Legal voluntary euthanasia in Great or misleading information in 29% of of the report can be seen at Community Health Councils, the Britain moved a step closer in June, as 300 letters sent by the Derriford www.nao.gov.uk/publications/nao_ NHS watchdogs for patients’ the House of Lords agreed to give the Hospital in Plymouth. Inaccuracies or reports/02-03/0203623.pdf complaints, are to stay functioning Euthanasia Bill a second reading. This misleading diagnoses were found in until 1 December. Three years ago the means that Lord Joffe, who is 46% of these, while 22% did not Patients like jargon government announced plans to promoting the legislation, can present include information vital for patient abolish CHCs from 1 September more detailed proposals to follow up. A new study has shown that patients 2003 to make way for the new system parliament. If the bill becomes law, a Emergency Medical Journal 5/03 prefer medical terminology, rather

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News in Brief be reserved for those with The booklet has been pacemakers fitted. There have severe depression. For the full published in response to the been several cases recently Correction guidance and the RCP’s practice recommendations where exploding pacemakers The contact details for the viewpoint see raised in the Victoria Climbié have damaged incinerators Royal Medical Benevolent Fund www.nice.org.uk/pdf/59ectfullguidanc Inquiry Report. and where artificial hip joints published in the last edition of e.pdf and http://www.rcpsych.ac.uk/ www.doh.gov.uk/ have caused problems with Casebook were incorrect. The press/preleases/pr/pr_413.htm safeguardingchildren/index.htm grinders. email and website addresses are: Healthcare workers in Scotland The Health and Safety The following guidance has [email protected] / www.rmbf.org. have been given new advice on Executive (HSE) has issued been published since the last improving treatment for the two new guidance booklets: issue of Casebook: NICE has issued new guidance country’s 240,000 osteoporosis Safe Working and the Prevention of NICE – Use of to regulate the use of sufferers. The Scottish Infection in the Mortuary and Post electroconvulsive therapy electroconvulsive therapy Intercollegiate Guidelines Mortem Room and Safe Working www.nice.org.uk/ (ECT). NICE restricts the use of Network (SIGN), backed by and the Prevention of Infection in pdf/59ectfullguidance.pdf ECT to the rapid and short- NHS Health Scotland and the Clinical Laboratories and Similar SIGN – Management of obesity term relief of severe depressive National Osteoporosis Society, Facilities. They contain advice in children and young people or manic symptoms and published its new guidance on ranging from how to carry out a www.sign.ac.uk/pdf/sign69.pdf catatonia after all other 6 June 2003. Management of risk assessment to cleaning, SIGN – Diagnosis and treatment options have failed Osteoporosis can be viewed at disposal of waste and management of epilepsy in and suicide is a risk. Doctors www.sign.ac.uk/pdf/sign71.pdf monitoring employee health. adults www.sign.ac.uk must also advise of the side- The new guidance revises the /pdf/sign70.pdf effects and patients must The Department of Health has booklets first published in DoH and RCGP – A framework consent to treatment. The launched new guidance on 1991. Call HSE's InfoLine on for doctors and nurses with a Royal College of Psychiatrists safeguarding children.What to 08701 545500. special interest supported NICE’s work with do if you’re worried a child is being Doctors are reminded to check www.doh.gov.uk/pricare/ the launch of a new ECT abused is a concise booklet for when completing cremation gp-specialinterests/ accreditation service, but did those concerned with the forms if the deceased patient not agree that ECT should only welfare of children. has any artificial joints or

than the lay terms health charter was launched by the Royal doctors that the patient’s consent is professionals have been encouraged Society of Medicine and the charity needed before explanations can be to use. The research, published in Action for Victims of Medical given to third parties. It is also Family Practice,says that patients Accidents (AVMA) in June. It aims important to make sure that you feel reassured that their problems to change the ‘blame’ culture, so have established all the facts before have been taken more seriously if when doctors make mistakes the you give the patient or family an doctors apply the medical labels, emphasis should be on learning to explanation of what went wrong. such as ‘tonsilitis’ instead of ‘sore prevent similar accidents The charter can be viewed in full at throat’.The lay labels were seen as happening and supporting the www.avma.co.uk/news.htm implying that the patient could take affected people – not on punishing care of himself, that the problem the doctor. Leaflet for would be short-lived and that it was The charter, which has been well the patient’s fault. received by doctors’ and patients’ private patients http://fampract.oupjournals.org/cgi/co groups alike, says doctors ‘should The Federation of Independent ntent/abstract/20/3/248 be supported in reporting errors Practitioner Organisations (FIPO), honestly and openly without fear which comprises professional FIPO’s leaflet is intended for Charter of of unreasonable consequences’. committees and speciality groups both patient and doctor as a Another of its principles is that if involved in private practice, has guideline for promoting good Understanding an injury has occurred due to produced an information leaflet on practice and positive relationships. Doctors’ and patients’ human error, the patient or their the rights and responsibilities of the It is endorsed by the medical organisations and individual next of kin should be informed private patient. Because the protection organisations and the doctors are being encouraged to and have the circumstances fully independent health sector works Patient Liaison Group of the Royal sign up to the values contained in a explained. differently to the NHS, it tells College of Surgeons of England. new ‘Charter of Understanding MPS has recommended this sort patients what to expect from Copies are available from between Doctors and People of open approach for more than 20 private care and their role in getting [email protected] or affected by Medical Accidents’.The years, but it is worth reminding successful treatment. www.fipo.org

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Acute headache Diagnosing acute headache Avoiding pitfalls – a guide to practice

By Sean Kavanagh, MRCP(UK) again, see box 2. Many headache diagnoses For reasons that are not clear, Mrs K went can be reached on the basis of history alone, to an optician who noted right inferior visual but examination is essential – see box 3. field loss, suggesting Dr C seek an This article uses cases dealt with ophthalmological opinion. A non-urgent by MPS to illustrate the potential Diagnosis referral was sent that day. On the same day pitfalls encountered in treating The crucial thing is to assess the overall the ESR result came back – grossly elevated patients with acute headache. It is combination of symptoms and signs and at 83 mm/hr. Dr C took no action on this a general guide and is not come to the most likely diagnosis, with the result, nor did he forward it to the exhaustive. Not all of the ‘not to miss’ causes kept high in the ophthalmologist. differential list. This is illustrated by the Two more weeks passed before Mrs K was diagnoses discussed necessarily following case. diagnosed as having giant cell arteritis in the present acutely, but they may do ophthalmology clinic. Immediate steroid so, or be time-sensitive, in terms Case 1 therapy relieved her symptoms, but she was of preventing avoidable sequelae. Temporal delay in left with permanent disabling visual impairment. temporal arteritis We consulted an expert in general Headache is a common symptom in primary Mrs K, a previously fit 75-year-old, went to see practice. In her opinion, Dr C could be and secondary care. The list of differential Dr C, her GP,because she’d felt generally criticised for not acting upon the ESR result diagnoses is immense – numbering several unwell and lost her appetite. She’d recently lost – as it was pathognomonic in combination hundred.1 Most are benign, but there are several kilograms and had back and leg pains. with the history. An expert in geriatrics conditions it is imperative not to miss – see Dr C’s notes don’t record a history of reported that Dr R should have had giant cell box 1. headache but Mrs K’s daughter later stated arteritis higher in the differential diagnosis that her mother had suffered head and jaw list, and that he should have asked History pain from the start of her illness. When Mrs specifically about jaw claudication, formally A useful template for taking a history in K later attended her local hospital, she gave a examined the visual fields and palpated the headache sufferers can be found at clear account of these symptoms. It may be temporal arteries. In light of these opinions, www.bash.org.uk (British Association for the that Mrs K didn’t volunteer this information the claim was settled. Study of Headache’s website). Box 2 (page 11) when she saw Dr C, but it would have been illustrates relevant historical and diagnostic wise to ask specifically about these Often, intuition based on experience factors, useful in differentiation of the symptoms in an older lady with weight loss brings the clinician to the correct cause. A important diagnoses in acute headache. The and myalgia. good rule to follow, if you feel you lack the history needn’t be overly detailed, depending Some weeks later, Mrs K went back to Dr pertinent expertise, is to ask yourself if any of on one’s confidence in this field. It is C. She was suffering from ‘black spots in the conditions in the ‘not to miss’ list important to establish the nature of the front of her eyes’ and had lost more weight. (particularly the common ones), could headache’s onset and whether or not this type Dr C asked Dr R, a locum consultant possibly be to blame, referring the patient to of headache is novel to the patient. At a geriatrician, to make a domiciliary visit. a specialist if the answer is ‘yes’. minimum, one should ascertain the standard Dr R noted a history of loss of half of Mrs Unfortunately, the specificity of headache ‘sieve’ of information relating to the nature, K’s visual field, which had apparently cleared symptoms and signs can be low. For site, character and aggravating/relieving up. Mrs K’s daughter later disputed the example, nausea and photophobia are factors of the pain. Useful associated features resolution of this symptom. Dr R ordered common to migraine, meningitis and intra- to ask about include photophobia, nausea, tests, including ESR, suggesting referral to an cranial haemorrhage, and can exist with any syncope, seizures and visual symptoms – ophthalmologist. sudden, severe headache.

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Acute headache

A point to remember regarding signs of meningeal irritation in meningitis is that, where the illness is septicaemic, such signs will be absent, as the meninges are not involved. In the following case, for example, the doctor was reassured by a lack of neck stiffness. Even where meningeal infection is present, it is common, especially amongst children, for neck stiffness and a positive Kernig’s sign to be absent.2 For this reason one should never rely on the absence of these signs as excluding meningitis or septicaemia.

Case 2 Suspecting septicaemia Miss H was 17 when she became unwell one evening. Her parents arranged a home visit from the local GP co-operative. Dr M visited at 9pm, and elicited a history of sudden fever, headache and leg pains since 5pm. Dr M found a temperature of 37.8oC, tachycardia and an absence of neck stiffness. Dr M tested straight-leg raising, but didn’t test for Kernig’s sign. Dr M diagnosed viral illness. By 5.30 in the morning, Miss H was vomiting and had a rapidly spreading, blotchy, purple rash. Her usual GP was now on duty and sent her to hospital with suspected meningococcal illness. The referral letter stated there was no photophobia or neck stiffness. Miss H was drowsy but rousable when she got to hospital, where meningococcal septicaemia was confirmed. Miss H had a stormy course in ITU, needing bilateral above-knee amputations. She subsequently suffered hypo-adrenalism and epilepsy. Miss H’s parents launched legal proceedings against Dr M, alleging Box 1. Causes of acute headache not to miss incomplete examination (failure to do Kernig’s test), and a failure to heed their Relatively Common Condition/Acute Headache Presentation warnings that she had an altered level of • SUB-ARACHNOID HAEMORRHAGE (SAH) consciousness. • STROKE – HAEMORRHAGIC & ISCHAEMIC We vigorously defended the case to trial, • MENINGITIS & ENCEPHALITIS (M&E) having expert GP and infectious diseases • GIANT CELL (TEMPORAL) ARTERITIS (GCA) opinion that Dr M’s clinical approach was • PRIMARY ANGLE-CLOSURE GLAUCOMA (ACG) reasonable. We asserted that neck-stiffness and photophobia would be absent as Less Common Condition/Acute Headache Presentation warning signs, this case being due to • IDIOPATHIC INTRACRANIAL HYPERTENSION (Formerly Benign Intracranial septicaemia, not meningitis. The crux of the Hypertension/Pseudotumour Cerebri) (IIH) case rested on the parents’ statement that Dr • SUB-ACUTE CARBON MONOXIDE TOXICITY (CMT) M had discounted their concerns about Miss • DURAL TAP OR TEAR (DT) H’s impaired consciousness level. Some • HYPERTENSIVE ENCEPHALOPATHY (HE) expert opinion did concur that this should • CEREBRAL VENOUS/DURAL SINUS THROMBOSIS (DST) have warned Dr M that something was • MASS LESIONS PRESENTING ACUTELY (Tumour, Abscess, Parameningeal Infection, seriously wrong. The judgment was in favour Intracranial haematoma of parenchymal, subdural or epidural types) (ML) of Miss H and she received a substantial settlement and costs.

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Continued from page 9 Reviewing the diagnosis sixth cranial-nerve palsy and bilateral facial An article on keeping records of telephone A common cause of claims is a failure to weakness. He could walk only with a Zimmer consultations can be found in Casebook.8 A review the diagnosis, ending in death or frame. These deficits were due to Guillan- recent paper on the use of an Australian disability due to fulminant meningitis. The Barré syndrome. He suffered tinnitus due to telephone-triage system9 states that headache signs of meningitis can develop in minutes to direct cochlear damage. guidelines are in the ‘top ten’ that they use. A hours. Their absence, at an earlier assessment Legal action against Dr P (but not Dr D), case discussed by the health and disability by yourself or a colleague, does not exclude alleged failure to properly assess Mr L. commissioner of New Zealand, regarding their subsequent rapid emergence. One Experts stated that Dr P faced a common set meningitis and telephone consultation, is should always review the initial diagnosis in of symptoms and had acted reasonably, if illuminating. the light of changing clinical information. both photophobia and neck stiffness had Visit www.hdc.org.nz/opinions to view the This is true of all cases of acute headache. been asked about on the telephone. In the commissioner’s report. Nobody expects doctors to always absence of a record about photophobia, it The next two cases demonstrate the diagnose meningitis in the early stages of was impossible to defend Dr P’s handling of importance of listening to your patient, every case, but a failure to re-assess a the consultation. examining them properly, recording your deteriorating clinical scenario is usually seen One expert was dubious about the findings and reviewing the diagnosis in the as sub-standard care. Burns’ review3 gives suitability of assessing suspected meningitis light of this information. Where acute this useful golden rule, ‘If a patient presents by phone – ‘Dr P admitted that meningitis headache persists, or becomes more severe, twice within 24 hours to the same practice or was in his mind by asking Mrs L to observe in a normally fit person without a history of hospital, with headache and vomiting, one neck flexion, but failed, by not visiting and previous troublesome headaches, you should should consider other causes, apart from examining Mr L, to put himself in a position hear alarm bells. migraine, before discharging the patient.’ to make a reasonable assessment of the Failsafe follow-up arrangements and good situation, and this was sub-standard care.’ Case 4 communication between teams responsible The claimant was unable to establish Cerebrally impaired for patients at different times, in both causation for any injury other than the primary and secondary care sectors, are deafness. Expert opinion asserted that the or just drunk? essential to avoid disaster when there is a neuropathic sequelae wouldn’t have been Mr T had recently moved to the South of rapid change in clinical condition. An improved by earlier treatment. On this basis, England. He liked a drink after work. One informative article in Casebook4 discusses we settled the case for a small sum to night, on his way home after a few pints in problems in the diagnosis of meningitis and compensate for loss of hearing. the pub, he injured his head and bruised his is online at www.musa.org/couldb.htm. body. He couldn’t recall how this had The case above shows the need for happened (a significant factor in his history). Some examples from MPS files communication and follow up, and the A week later he went to A&E, as he’d been potential danger of relying on telephone unable to work due to somnolence, poor Case 3 consultations to exclude meningitis. When it appetite, blurred vision and poor Drawbacks of telephone comes to paediatric illnesses, the difficulty in concentration. providing appropriate, competent Dr S saw him there and noted that Mr T consultation telephone-triage systems, even amongst appeared ‘rough’ and smelt of beer. Mr T Mr L went home early from work one day, trained and experienced operators, has been freely admitted to enjoying four or five pints due to a bad headache. He vomited on the well documented.5,6,7 of beer a day. He was fully oriented with a way home. His GP,Dr D, saw him there at One might conclude that telephone GCS of 15/15. A full neurological 7.30 pm, finding him feverish and shaky with management of potential meningitis is examination, including fundoscopy, was a bad headache, but no abnormal clinical foolhardy. However, febrile illness and normal. After seeing a normal skull x-ray, signs. Dr D diagnosed gastric flu and advised headaches are common, and management of Dr S diagnosed a post-concussion syndrome fluids and paracetamol. Dr D told Mr L’s wife such problems with telephone advice is with concomitant alcohol excess. He told Mr to ring for another visit, if things hadn’t current standard practice. If it is possible, T to register with a local GP,giving him a improved within 24 hours. one should avoid assessment of acute copy of his A&E card. Mr L deteriorated, so his wife telephoned headache by telephone. If this is not Mr T visited Dr F, a local GP,two days Dr P the next evening. She told him of the practicable, we recommend locating (or later. He told of his severe headache. Dr F previous visit, and Mr L’s severe headache, drawing up your own) protocols. noted a healing laceration over the occiput vomiting and tummy cramps. Dr P asked if We have had no success in finding good- and a smell of beer on Mr T’s breath. Dr F Mr L could flex his neck, which he could. Dr quality published protocols/guidelines for gave advice about drinking, and prescribed P advised continuing with fluids and taking telephone assessment of acute headache. If co-proxamol. some codeine that Mr L had at home. any readers are aware of such publications, There is no record of any neurological Mr L was very ill by the next morning. A we would be grateful to hear from them. It is assessment. visit by a third doctor resulted in his outside the scope of this article to provide Two weeks later Mr T went back to Dr F. immediate admission to hospital. He went to guidelines for telephone consultation for He told Dr F of his headache, pain behind ITU and pneumococcal meningitis was headache. We recommend that practices find the eyes, neck pain, exhaustion and inability diagnosed. good guidance in this area, and subject their to rouse himself from bed for work. Dr F Mr L was left with a blind right eye, a right current procedures to a risk assessment. tested visual acuity, finding 6/6(R) and

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Box 2. History taking/diagnostic pointers in acute headache

To establish the diagnosis of the following conditions, these features of the history, questions and investigations are useful (but not to be taken as absolutes). Classically Ask Distinguish from SAH Of abrupt ‘thunderclap’ onset, Worst headache ever? Any photophobia and Migraine by absence of previous episodes and often occipital. neck stiffness? Any fits/fainting? visual aurae (get patient to draw it, it is very Did it start during exertion/sexual intercourse characteristic).12 Cluster headache by absence of or orgasm? (such headaches, if transient, are unilateral ocular/nasal usually benign).14 symptoms13.Positively diagnose with neuro- imaging +/- LP.15,16,19

Stroke Of rapid and evolving onset, About previous stroke and vascular risk factors, Migrainous paresis by absence of previous with speech impairment and speech, visual fields, seizures, conscious level. episodes and quicker resolution, but may need unilateral limb and/or facial neuro-imaging to confirm. weakness. M&E Unwell, febrile, often confused About fever, conscious level, confusion, contact Migraine/SAH by presence of symptoms of or drowsy, with rash with illness, place of residence (e.g. student infection and evolving (rather than abrupt) (meningococcal septicaemia), halls), short-term memory (HSV encephalitis), confusion and altered consciousness. See or herpes simplex stomatitis travel (tick-borne or unusual viral previous Casebook.4 (rarely assoc. with encephalitides, legionella infection). pneumococcal). GCA Older patient (>50), evolving About jaw claudication (virtually Benign causes by presence of systemic onset with temporal pathognomonic) and ‘Are you able to brush illness/generally ‘not right’,visual symptoms pain/tenderness and associated your hair?’ (very specific for polymyalgia and weight loss. Confirm diagnosis with trunk-girdle myalgia and visual rheumatica, where deltoid pain has prevented ESR/temporal artery biopsy.17 impairment. this), scalp pain, visual field loss. ACG Accompanying monocular About haloes around lights, previous episodes, Non-ocular causes by presence of ocular pain with visual disturbance medication (may be iatrogenic). symptoms and signs. From cluster headache by and nausea. presence of corneal/pupillary signs. IIH Obese, young, female. About speed of onset (but headache can appear ML by lack of associated localising signs, and acutely), visual acuity, oral contraceptive use, presence of raised CSF pressure at LP with previous head injury. other investigations normal. CMT Notice drowsiness and About gas fires/boilers and colour of flame Other causes by arterial blood gases to estimate confusion on cold winter (orangey-yellow rather than blue).18 COHb level, or presence of cherry-red mucous evenings when at home, or membranes in advanced cases. worsening throughout day for the retired/unemployed. DT Following epidural, lumbar About procedures in other places and Other causes by history of possible dural puncture or head/spinal facial/head trauma in the past, CSF breach, and positive CSF rhinorrhoea trauma. rhinorrhoea, relation of headache to upright identification. posture (it gets worse).

HE Older patient, About compliance with anti-hypertensive Other causes on basis of presence of signs of undiagnosed/untreated therapy, vascular risk factors, cognitive malignant hypertension (particularly hypertension. impairment. fundoscopy), by use of neuro-imaging. DST Presents as stroke of whole About association with cough – see box 4. Arterial stroke by neuro-imaging/D-dimer cerebral hemisphere (where About relevant risk factors – see right. estimation. Systemic associations include severe dural sinus involved); dehydration and hypernatraemia, septicaemia, associated with cranial pregnancy, oral contraceptive use, pathology (particularly orbital haematological pathology, vasculitis, androgen cellulitis), or surgery. therapy, diabetes, CCF, malignancy, inflammatory bowel disease, anti-fibrinolytic therapy or nephrotic syndrome. ML Presents with headache noticed About trauma, weight loss, visual acuity, fever, Other causes by presence of a headache that when coughing, stooping or foreign travel, immunocompromisation, improves as the day goes on. Positively diagnose straining with an evolving neurosurgical procedures. with neuro-imaging. increase in severity.

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6/9(L). There is no record of fundoscopy or a should have been given to Mr T, and this fact neurological assessment. recorded). One expert commented,‘ … Dr F Twelve hours later Mr T lost failed to examine Mr T adequately, or at all, consciousness and became paralysed on the and failed to refer him for a CT scan and/or left side. He had a left fronto-parietal chronic neurological opinion.’ subdural haematoma with midline shift. He Another commented ‘ … a more thorough was left severely brain-damaged and unable examination of the eyes was indicated … as a to live independently. minimum … pupils should have been This case was settled out of court. checked to see if they were equal and According to A&E and GP experts, the reacting to light … optic discs should have failure of duty was on Dr F’s part, but firmer been checked to see if there was any evidence follow-up arrangements could have been of papilloedema … visual fields should have made at A&E (also, a head-injury card been checked by confrontation.’

Box 3. Suggested schema for examination of the acute headache sufferer This schema will not suit the practice of all it causes intense pain and distress to the reflex testing is sensitive for subtle Vth nerve clinicians, and will require adaptation to suit patient, indicating meningeal irritation. See lesions), and assess VIIth nerve motor your area of practice. It should serve well as an cases 2,3 & 4. (20s.) function in upper and lower face :‘screw up aide-memoire, but should not be considered • Examine any other systems that may be your eyes/give me a cheesy grin/keep your comprehensive. It may seem lengthy, but with relevant if your findings on general head still and look at the ceiling’.(30s.– 1min) practice it can be done in a total of 5–10 assessment suggest it. (variable) • Ears – Check hearing with a whisper of a minutes. The times in brackets estimate how • Consider extra-cranial causes of headache word 5–10cm from the ear. If it can’t be long it normally takes to complete each part of e.g. related to alcohol excess/withdrawal or heard, formally assess Weber/Rinne’s tests the examination. Not all parts of the systemic infection. See case 6. with a tuning fork. (10s. for whisper, 30s. for examination are necessary in every patient, Weber/Rinne.) Check balance by getting depending on previous findings and the Neurological patient to stand with eyes closed. (10s.) clinical context. CRANIAL NERVES • Mouth – Observe palate and tongue • Nose – Ask about change in smell movements – ‘Say aaah’,check General perception, and test if positive reply/ (orange masseter/pterygoid function, jaw jerk. (30s.) • Check temperature, BP & pulse. Quickly look peel and granulated coffee are useful and • Neck – Test sternomastoid and trapezius for general signs such as anaemia (or cherry- often to hand; use an odiferous, non-volatile function : ‘lift up your head from the red mucous membranes in CMT), jaundice, substance. 5–10s.) Check for nasal drip of pillow/put your chin on your left then right clubbing, cyanosis, rash, lymph drainage of CSF rhinorrhoea, and send fluid for testing shoulder/shrug your shoulders’.(30s.) the head and neck and tenderness of to confirm as CSF, if relevant (DT). temporal arteries (GCA). If you suspect a • Eyes – Observe – For corneal clouding or Limbs stroke, listen for carotid bruits. (Total 30s.–1 pupillary outline irregularity/fixity (ACG). • Test upper and lower limb tone, power, and min) Check pupillary reactions. Formally test eye reflexes. Ask about/test for any sensory • Assess whether or not patient is systemically movements. Is there evidence of disturbance. Check co-ordination using unwell by observing and talking to the ptosis/ophthalmoplegia/nystagmus/Horner’s finger–nose pointing and by asking the patient. Check if they are ambulant and syndrome? Check visual acuity with patient to run their heel rapidly up and down observe gait and balance. Ask carers/relatives newsprint/Snellen chart if available. the contralateral shin. (1–2 mins) if the patient is his/her normal self – and Examine visual fields by confrontation. • If you find any abnormalities, attempt to treat their responses as important clinical Ophthalmoscopy is mandatory and its localise the lesion within the CNS and arrive information – see case 2. (30s.) omission is a frequent reason for failing to at a diagnosis, if possible. • If you find abnormality in the above diagnose, leading to litigation. Ensure that the assessment, then formally test conscious level optic cup and disc margins are clearly seen Documentation with Glasgow Coma Scale (see (if lost, suggests papilloedema – consider Record what you have found, including www.trauma.org/scores/gcs.html), and test ML) and briefly examine the retina for important negatives. Failure to record higher cerebral functions looking for evidence of flame/sub-hyaloid/vitreous ophthalmoscopy, Kernig’s sign, neck stiffness, evidence of disorientation, confusion, haemorrhage (SAH) – photos of these photophobia and assessment of consciousness dysphasia or dysarthria. (20–30s.) retinal findings are available.19 In HE, typical are recurring themes in litigation. As always, • Always check for neck stiffness and retinopathic findings should be plain keeping a clear, full, contemporaneous record photophobia (use pen torch to test to see. In IIH, papilloedema may be is the best way to avoid difficulties if a objectively), and formally test Kernig’s sign. the only abnormality in the whole complaint or litigation ensues. In evidential Kernig’s manoeuvre consists of the extension examination. (2 mins) legal terms, if something isn’t recorded as of a flexed knee, with the hip in flexion and • Face – Briefly test sensation in all three being done, then it’s virtually impossible to the patient lying supine. The sign is positive if divisions of the trigeminal nerve (corneal prove it was done.

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Case 5 Box 4. Smart handles and red flags useful in Missed subarachnoid headache diagnosis Adapted from a review by Dr Christopher Hawkes20 haemorrhage • Smart handles are shortcuts that suggest a disease of the skull and ask about changes in Mr V,a fit and healthy 26-year-old, became particular diagnosis, or shorten the differential head-shape/hat-size and order a skull x-ray. suddenly unwell. According to his wife he list. rapidly became confused, staggered about and • Red flags are warning signs that should alert • ‘Thunderclap’ headache See box 2 & case 5. complained of a very severe headache. He was you to the need to reconsider your diagnosis. Such a headache starts abruptly and is likened visited at home by his GP,Dr E, but no notes • Their combined use can allow one to reach a to a blow to the head (as if by a hammer), were recorded for this visit. diagnosis more quickly. usually over the occiput. One must exclude Dr R, from the same practice, reviewed Mr • They are not scientifically validated, so they SAH with neuro-imaging and, if this is normal, V the next day. The notes state,‘Unwell with must be used with caution. an LP,looking for xanthochromia (at least 12 vomiting. O/E Abdo NAD. No neck stiffness. hours after headache onset, although a recent Rx domperidone 10mg, 4 tabs left.’ • Cough headache – Where a patient suffers a paper has suggested the utility of preceding CT Mr V remained unwell and Dr R visited headache initiated by coughing, stooping or with LP16), or high CSF red-cell count, not again the next day. Dr R noted that Mr V was straining (all manoeuvres which raise intra- diluted over three serial samples. In the absence still nauseated and had severe headache; his BP cranial pressure), there is about a 50/50 chance of confirmatory findings for SAH, migraine is was normal and there was no fever or neck that they will have a posterior-fossa the likely culprit. Ask about the relation of the stiffness. Dr R diagnosed post-viral illness and ML/cortical-venous thrombosis/raised intra- headache’s onset to coitus/orgasm/exertion – gave simple analgesia. cranial pressure. Although it is not that see box 2 and case 5. A week later Mr V needed another home common for mass lesions to present with acute visit. Dr S attended and recorded a pain under headache, they can do so, and this can • ‘First and worst’headache – If a patient not Mr V’s right ear and normal neck movements. commence from an episode of coughing. prone to headache complains of this, then this Dr S diagnosed right otitis media and Distinguish this from the common observation acts as a red flag for a serious cause, needing prescribed co-amoxiclav. that pre-existing headaches may be worsened investigation. SAH or vascular tumours should A week later, Mr V died after collapsing by coughing. be at the top of the list. suddenly at home. A postmortem showed a large subarachnoid haemorrhage. • Unilateral headache and ipsilateral symptoms • Unilateral excruciatingly painful eye and We were advised by GP and neurological If symptoms/signs are on the same (‘wrong’) headache – This suggests ACG or cluster experts. Absent or terse clinical notes made the side as a unilateral headache, then migraine is headache. The eye may be red and sore in case difficult to defend. All the experts were quite likely to be the cause. It is a cause for both. ACG sufferers will have a cloudy cornea unhappy with the follow-up arrangements. concern to find hemiparesis or and a fixed pupil. See box 2. Cluster headache They felt that if Mrs V’s account of events was hemianaesthesia with headache. One should (M:F preponderance of about 5:1), often correct, the care received by Mr V fell below an put vascular abnormalities and tumours at the causes severe lacrimation and/or nasal acceptable standard. top of the list. congestion. It occurs in bouts, and there is Meningeal irritation was obviously usually a clear history of previous episodes. A suspected, but infection seems to have been the • Persisting, severe headache in an older patient condition known as Short-lasting Unilateral only cause considered, despite the characteristic Whilst this can be due to spondylosis or Neuralgiform headache attacks with history for subarachnoid haemorrhage. The tension-type headache, it should be considered Conjunctival injection and Tearing (SUNCT) case was settled for a six-figure sum. as GCA until proven otherwise. This is can present similarly. It is usually episodic especially true if the patient is ‘not herself’,has and quite short-lived (minutes long). It is SAH can be very hard to diagnose, even with lost weight, or appears depressed and part of a group of relatively rare conditions the benefit of cerebral imaging. If there is any downcast. Jaw claudication, visual disturbance known as the trigeminal autonomic suspicion of this illness in a primary-care or the presence of myalgia restricting limb- cephalalgias, which include cluster headache. setting, with acute headache and associated movements clinch the diagnosis. See box 2. Their characteristics are well described in symptoms/signs suggesting meningeal GCA is confirmed by significantly raised Flippen’s review11. One should consider irritation, referral for further assessment is ESR/PV,or typical pathology on examination trigeminal neuralgia where there are short mandatory. of a temporal-artery biopsy. If these findings (seconds long) episodes of excruciating Following head trauma, retrograde amnesia are not present, one should think of Paget’s unilateral headache/facial pain. of duration greater than an hour (as in case 4) is an indicator of severity. One should be Case 6 with little benefit, for suspected migraine. aware that intoxication can cloud the clinical When she developed colicky lower- picture following head injury. It is important Not all headaches abdominal pain and, later, heavy periods that it doesn’t cloud your objectivity when come from the head associated with acute, severe pain in her assessing an intoxicated patient. lower pelvis, she saw Dr J who, finding a The last case shows how diagnoses can be Mrs B had been suffering from acute, severe mass in her left iliac fossa, arranged an missed if one fails to consider causes outside pre-menstrual headaches for three years. urgent gynaecological referral. the typical anatomical/systematic culprits for a She’d consulted her GP,Dr J, on several Mrs B had had an IUCD in situ for 14 given set of symptoms. occasions and he had prescribed pizotifen, years, but this had never been checked. The

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References 1. Evans RW. Diagnostic Testing For The Evaluation Of Headaches. Neurol.Clin. (1996) 14(1): 1–26. 2. Oostenbrink R et al. Signs Of Meningeal Irritation At The Emergency Department: How Often Bacterial Meningitis? Paediatric Emergency Care (2001) 17(3): 161–4. 3. Burns R. Pitfalls In Headache Management. Australian Family Physician (1990) 19 (12): 1821–6. 4. Campbell AGM & Cranfield F.Could It Be Meningitis? MPS Casebook(1996) UK No. 8:3–6. This article did not appear in the International edition; copies of the UK article are available on request. 5. Isaacman DJ et al. Pediatric Telephone Advice In The Emergency Department: Results Of A Mock Scenario. Pediatrics (1992) 89(1): 35–9. 6. Greitzer L et al. Telephone Assesment Of Illness By Practising Paediatricians. J. Paediatrics (1976) 88 (5): 880–2. Continued from page 13 7. Yanovski SZ et al. Telephone Triage By Primary Care Physicians. Pediatrics (1992) 89 consultant gynaecologist, suspecting on errors unconnected with its diagnosis, but (4–Pt.2): 701–6. actinomycosis, removed the IUCD and did a it illustrates the difficulties involved in 8. Mackenzie P.Recording Telephone laparotomy, revealing a severely swollen treating a condition without being absolutely Consultations. MPS Casebook (1998) UK No.12, fallopian tube and ovary, adherent to sure of the correct therapy, and in failing to Int. No.10: 7–8 & 6 respectively. surrounding structures. use all the available clinical information to 9. Turner VF et al. Telephone Triage In Western Mrs B underwent hysterectomy and review a diagnosis. If one isn’t sure what the Australia. Medical Journal Of Australia (2002) 176(3): 100–3. bilateral salpingo-oophorectomy. correct therapy is for a relatively uncommon 10. Steiner TJ. Common Headache – With Traps Microbiological analysis confirmed condition, look it up or take advice; otherwise For The Unwary. MPS Casebook (1998) UK actinomycosis, which was succesfully treated you invite complaints and litigation. No.10, Int. No.9: 3–6. with a month-long course of co-amoxiclav. 11. Flippen CC(II). Pearls And Pitfalls Of It later transpired that, within a few Conclusion Headache. Seminars In Neurology (2001) months of Mrs B first presenting to Dr J with A previous article in Casebook10 gives an 21(4): 371–6. 12. Steiner TJ. Headache. BMJ (2002);325:881–6. pre-menstrual headache and bouts of excellent overview of the common causes of 13. Levin M. The Many Causes Of Headache. abdominal pain, a routine cervical smear test all headaches, their characteristics and Postgraduate Medicine (2002) 112(6): 67–81. had shown actinomyces-like organisms, for diagnostic criteria. Burns’ review3 provides 14. Green MW. A Spectrum Of Exertional which Dr J had inappropriately prescribed pertinent information for primary care Headaches. Med. Clin. North. Am. (2001) metronidazole. doctors and non-physicians, and the articles 85(4): 1085–92. A claim was brought against Dr J for by Flippen,11 Steiner,12 and Levin13 are 15. Wasserberg J & Barlow P.Lesson Of The Week: Lumbar Puncture Still Has An Important failing to act appropriately in response to the recommended for those who want a more Role In Diagnosing Subarachnoid Haemorrhage. cervical smear report, and for a failure to detailed overview. The International BMJ (1997) 315: 1598–9. check the IUCD. We settled the claim, Headache Society’s website – www.i-h-s.org 16. Schull MJ. Lumbar Puncture First: An advised by experts that the combined clinical – is also an extremely useful and detailed Alternative Model For The Investigation Of Lone information should have alerted the GP to a resource. The same is true of the website of Acute Sudden Headache. Academic Emergency diagnosis of infection associated with the The British Association for the study of Medicine (1999) 6(2): 131–6. 17. Hall JK et al. The Role Of Unilateral Temporal IUCD. Headache at www.bash.org.uk. Artery Biopsy. Ophthalmology (2003) Mrs B’s headaches were probably This brief overview of the approach to 110(3): 543–8. constitutional features of her pelvic acute headache should help you to avoid the 18. Walker E. Chronic CO Exposure and infection. The association between headache common pitfalls encountered in this area of Headache (Rapid Response to Ref.12 above) on and actinomycosis is described in a recent practice. By digesting the lessons to be learnt www.bmj.com (2002). review,21 which can be found at from the cases, taking note of the pointers to 19. Edlow JA & Caplan LR. Diagnosis Of www.familypractice.com. diagnosis, and accessing the resources Subarachnoid Haemorrhage In The Emergency Department. Emerg. Med. Clin. N. Am. Migraines can be associated with menses discussed in the article, we hope you derive (2003);21:73–87 and don’t always respond to prophylactic benefit for yourself and your patients. 20. Hawkes C. Smart Handles And Red Flags In therapy, so it would be unfair to expect Dr J to Neurological Diagnosis. Hospital Medicine have reached the diagnosis on this basis alone. Acknowledgement (2002) 63(12): 732–42. Our thanks to Dr Tim Steiner for kindly 21. Petrone LR et al. Actinomycosis – An Unusual This was an unusual and quite rare cause looking through a draft of this article and Case Of An Uncommon Disease. J. Am. Board. Fam. Pract. (1999) 12(2): 158–61. of headache, and the legal action was based suggesting improvements.

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Compensation culture

The rising cost of injuries

www.comstock.com By Ross Davies which make defending the reputation of the ‘I won’t take less than £37,500,’said the member a paramount workman, minutes into the consultation at the concern. lawyer’s office. The lawyer was retained by the workman’s Social attitudes trade union, and the consultation was to see to risk what grounds there were for suing the man’s Litigation avoidance is employer. The workman had stumbled at the flip side of litigation work,twisting an ankle. Had the lighting been culture, and it blights poor, the corridor slippery, or negligence everyday life. otherwise proved, the injury might have rated Councillors ordered the about £2,000 in compensation. removal of a children’s But as the conversation progressed, it swing, hanging from an became clear there were no possible grounds oak tree for many years for negligence. It had been an accident, a minor at Sheet, Hampshire. misfortune, and indeed the case was never They fear parents will brought. Why, then, the grotesque inflation of sue if a child is hurt. expectation, from £2,000 to £37,500? ‘Because’, Schools close the lawyer recalls,‘our client had read of a jury playgrounds, and give in America awarding the dollar equivalent of up rough sports. The that sum for a similar injury, so in his mind that idea that life involves an became the going rate.’ acceptable element of This story crystallises three assumptions risk is no longer central to what Frank Furedi calls the ‘litigation acceptable. culture’.Firstly, having been hurt, the man Litigation culture automatically assumed that it had to be may make life harder, somebody’s fault, not just his bad luck. but it has its roots in Secondly, he assumes that compensation is due positive social changes. and, thirdly, high expectations hold sway from The professions, the United States. The prospect is of a risk-free medicine among them, windfall profit, as his trade union would have undermines relations of trust and the sense of are more open nowadays and wish to be, and funded any legal costs, had an action been personal responsibility’. be seen as, accountable. The public is better brought. In the US, litigation culture has precipitated educated, better-informed, and expects more a national crisis in medicine. In the UK, from life. But politicians and lawyers are not in Three-quarters of those polled by Mori between 1989–90 and 2001–2002 the cost of the business of discouraging expectations, with in the UK say they are willing to sue for clinical negligence claims against the National results in healthcare that benefit neither patient personal injury compensation. Health Service more than doubled, from £221 nor practitioner. million to £446 million. In Australia, United Medical Protection, insurer of over half of the The American experience Blame and gain country’s doctors, was driven into provisional US healthcare is cracking up under a legal In Courting Mistrust (Centre for Policy liquidation. system which encourages litigiousness with a Studies), Dr Furedi, a sociologist at the The extent to which the litigation culture conditional fee system, under which half or University of Kent at Canterbury, argues that thrives is often hidden from those who, unlike more of any award may go to the lawyer rather the unremitting pursuit of someone or doctors, are not its prime targets. In the UK, for than the complainant. Prosecuting counsel also something to blame and seek compensation example, all but a few personal injury cases are has a big say in the composition of the jury. US from, irrespective of liability,‘directly settled out of court. Unpleasant publicity is avoided, and many settlements are ‘without In the UK, a cancer sufferer was granted Legal aid was granted to a British man prejudice’ (no admission of responsibility). legal aid to sue the NHS for loss of earnings to sue for ‘personal injury and loss’ Insurers, with an eye to the bottom line, and trauma because he was still alive because a local council was allegedly routinely ‘roll over’ to reduce legal costs, three years after the diagnosis of his negligent in not having him adopted irrespective of the justice of a case. The condition, when he had been told he might as a child. exceptions are mutual organisations like MPS, have as little as three months to live. Continued on page 16

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Compensation culture

Continued from page 15 Rising costs leave UK schools only legal fees. Unsurprisingly perhaps, the number juries are free to award ‘punitive’ damages, as £250 million of extra funding this year. of lawyers in England and Wales has doubled well as ‘economic’ damages for loss of work or Last year, schools paid out £200 million in the last 20 years. They can now compete, medical expenses. Juries use their freedom to to litigious parents. and chase business. punish, but will also inflate an award to see that About 1,000 conditional fee personal injury the victim is left with something after the Emergency departments are losing staff; firms have sprung up since 1996, when lawyers have taken their cut, especially as the neurosurgery is delayed because practitioners contingency fees were introduced. Members of payout is likely to be reduced at appeal. find insurance cover hard to find or afford, now the public have been approached by It has gone into world folklore that an that St Paul and other insurers are moving out salespeople from at least one such firm, American jury awarded a woman US$2.9 of medical cover. In ‘crisis’ states such as offering to act as witnesses in bogus bus-crash million because she scalded herself with Pennsylvania, obstetricians and orthopaedics claims. McDonald’s coffee in a car. The jury awarded specialists are retiring early, limiting their her US$160,000 economic damages – practices or moving to another state. What next? accepting she was partly to blame – and US$2.7 Ironically, litigation culture may be taking root million punitive damages. What the woman The phenomenon spreads beyond American shores at the same time as actually received, we may never know: American jury awards also boost expectations Americans tackle their crisis in medicine. A McDonald’s settled out of court. It is these elsewhere, even where juries cannot be packed, new federal health bill, passed by the House of sensational jury awards, not the more modest and the scope for awarding punitive damages is Representatives, but currently stalled in the limited by law. In the UK, the number of Senate, would allow unlimited economic A bodybuilder claimed £15,000 damages, personal injury cases at county and High Court alleging negligence by an MPS GP member, level has fallen over the last 20 years, but that is A British sailor returned home after in failing to diagnose a lump on the chest because most cases are settled out of court. Or, service in the Iraq campaign to find that a which later proved to be an epigastric hernia. more accurately, in or out of other sorts of legal neighbour was suing him for his share MPS fought and won the case, but because or administrative arenas. Industrial tribunals of the cost of mowing a communal lawn the claimant was legally aided, costs of about are one example. during his 86 days at sea. £15,000 could not be recovered. MPS According to the business intelligence group defended, regardless of cost, because records Datamonitor, the cost of personal injury damages, but cap punitive damages at showed that the claimant was a frequent compensation in the UK, £3.7 billion in 2002, US$250,000, or twice economic damages, attender at the surgery whose every may treble in five years. Psychiatric distress is whichever is the greater. complaint had been recorded, treated or now a basis for compensation claims, and it is In the UK, 2,500 employees of The Accident referred to a hospital, and that he had never now open to service-people and police officers Group, a conditional fee personal injury group, mentioned the lump. to demand compensation for incidents were made redundant after questionable claims previously held to go with the job. One in 220 led to ‘continual battles with the insurance final outcomes, that make headlines around British soldiers makes a claim, and police industry’.The litigation culture may have hit a the world. compensation has doubled in three years to snag here, however, as aggrieved employees Medicine is a high-risk profession in a full- £330 million, or 7% of payroll. were quickly offered representation by another blown litigation culture, such as that of the US, The incorporation into UK law of the conditional fee concern – for 33% of any award where the average medical liability award is European Convention on Human Rights at employment tribunal! now US$3.5 million, and liability premiums allows individuals to pursue claims against have risen 45% in especially contentious fields public bodies in the UK courts, rather than A former labourer threatened to sue for loss of such as orthopaedics and obstetrics. having to go to the European Court of Justice. earnings and cost of care, asserting that his GP, One result, says a 2002 study by Wirthlin Experience in Canada and New Zealand with an MPS member, had been negligent 10 years Worldwide, is that over three-quarters of rights legislation, suggests the UK will see an earlier in failing to diagnose spinal arthritis or Americans now worry that their access to increase both in litigation, and in the courts’ refer him to hospital for back pain after an medical care could suffer. In many cases, they willingness to extend the number of grievances injury at work. MPS refused to settle pre-trial are right. The American Medical Association that can be pursued to qualify for punitive for £10,000, whereupon the complainant sued now speaks of a ‘crisis’ of patient access in 18 damages. for £1.2 million. MPS had the man medically states, and of ‘serious’ problems in the rest. examined, and found no evidence of arthritis The costs although there was mechanical back pain A dental patient claimed £4,000 for damage The litigation culture costs the UK about £10 which had become chronic. Examination of the to a crown, allegedly when the anaesthetist billion a year, or about 1% of GDP,and is MPS member’s records disclosed that the GP intubated him with a Laryngeal Mask Airway increasing by 15% annually, according to the had not seen him until after the alleged tube before surgery. Having consulted the Faculty and Institute of Actuaries. About a accident, by which time any untreated inventor of the soft, flexible LMA, MPS third of the costs go on ‘legal and mechanical pain would have become chronic defended the case, refusing an offer to settle administrative expenses’.Premiums for and untreatable. The case was withdrawn. for £3,500 and costs. The court found for the employers’ liability in the UK have risen by Dr Davies writes for the Financial Times and is a MPS member, and MPS was able to recover 100% in five years, says the Association of non-stipendiary research fellow of Harris its costs of £13,500. British Insurers: 40% of claim costs goes out in Manchester College, Oxford

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Case reports

Case reports

KEY

ANAESTHETICS DERMATOLOGY GENERAL GENERAL SURGERY HAEMATOLOGY PRACTICE

OBSTETRICS & ONCOLOGY ORAL SURGERY ORTHOPAEDICS RADIOLOGY GYNAECOLOGY

VASCULAR SURGERY

We publish case Medication error reports as an aid to MPS members, to Inspect before you inject alert them to pitfalls that have caught their colleagues unawares. We believe that these are an invaluable risk-management tool and, as such, they should be rooted in fact – i.e. based on actual events. The following narratives are taken from MPS case files from around Mr O had suffered with an anal injecting 7–8 ml of phenol the rest of his inpatient stay. the world, with some fissure for some time. He’d been solution, he stopped, noticing that When Mr O brought a claim of alteration of the referred to Mr F, consultant the injected area was turning negligence, we settled out of court surgeon, who’d decided on an black. for a moderate sum, sharing half facts to preserve examination under anaesthesia It turned out that the solution the liability with the theatre confidentiality. (EUA) with a view to lateral anal was 80% phenol, not 5% in oil, nurse’s employer. sphincterotomy, after a course of which is the usual strength for this conservative treatment. procedure. Mr F flushed the area Commentt Mr F performed the EUA, with alcohol and copious Although it may seem a tedious attempting sigmoidoscopy, which quantities of water. Mr F spoke to ritual to check the quantity and was hampered by faecal loading. the Poisons Unit, who advised nature of an injectable substance Mr F used a Parks anal retractor overnight observation on ITU, before administration, there are Delayed diagnosis and found a benign-looking due to the risk of adverse systemic extremely good reasons for doing so, Tardy surgical fissure, from which he took a reactions to the phenol. Mr O as this case clearly shows. Even if biopsy. He also found moderate suffered some transient hepatic you draw up an injection yourself, intervention vascular haemorrhoids and dysfunction, which settled you should make it standard Mr W, a diabetic gentleman in his decided to treat them by spontaneously. practice to double check what you sixties, saw his GP because of sclerotherapeutic injection. Four days later, Mr F and a are going to inject into a patient, by abdominal pain and vomiting. His He took a syringe of phenol, colleague, Mr A, performed a any route, before you do so. Many doctor suspected appendicitis and filled by his assisting theatre further EUA, finding extensive examples of maladministration of made an urgent referral to his nurse. Mr F wasn’t asked to check confluent ulceration of the anal injectables feature in the medical local hospital. He was seen there the ampoules from which the canal with indurated tissues at the and lay press each year. If you give by Mr T, a locum consultant. No syringe had been filled, nor did he level of the pelvic floor. Mr A the wrong substance, or give it by notes were kept of the initial ask to see them. He started to performed a trephine-loop the wrong route, you can cause consultation. inject the haemorrhoids, using a sigmoid-colostomy. Mr O irreparable damage to your Mr T later stated that he found standard technique. After remained under Mr F’s care for patients. Continued on page 18

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Case reports

Continued from page 17 Failure to investigate Mr W to be jaundiced, with abdominal abscesses. He tenderness in the right upper and performed a rigid sigmoidoscopy lower quadrants. Mr T suspected but found nothing abnormal. acute cholestatic disease, ordering Eleven days after admission, Mr Treat pigmented ski an urgent ultrasound scan. He B decided to take Mr W to theatre ordered a sliding-scale where he carried out a laparotomy. Mr F was a forester in his forties. glucose/insulin infusion and He found intra-abdominal pus, a He went to see Dr N, his GP,for prescribed IV cefuroxime, walled-off right-sided abscess and advice about two skin lesions – metronidazole and analgesia. a thickened, hard appendix, which one appeared to be a sebaceous Mr W was pyrexial and he removed. cyst on the left shoulder, the hypotensive on admission. Initial Unfortunately, Mr W suffered other a pigmented lesion on his investigations showed normal septicaemic shock and multi-organ chest. Dr N booked Mr F in to U&Es, an elevated bilirubin of 122 failure in the postoperative period. have the lesions removed on the µmol/l (NR 4–17), glucose 11 He died 22 days after his admission. minor-surgery list at the mmol/l and a white-cell count His family sued, alleging clinical practice. (WCC) of 5 x–109 /l (83% negligence by Mr T and Mr B. The surgery was carried out a neutrophils, NR 4–11). We consulted a surgical expert month later. The sebaceous cyst The scan showed no evidence of who accepted that the jaundice was was removed in its entirety, and biliary obstruction. There were atypical and confusing, but was the lesion on the chest dilated loops of small bowel, also critical of the decision not to cauterised, in the belief that it seen on a plain abdominal x-ray. proceed to laparotomy, once was a naevus. No samples were Mr T was consulted about these imaging had excluded biliary sent for histology. findings and advised continuing obstruction. The expert A year later, Mr F returned to conservative management. commented,‘His temperature the surgery where he consulted The next day, Mr W was persisted in spite of antibiotics and another of the practice partners. consistently pyrexial with the WCC steadily rose … a mass He had developed a swollen, generalised abdominal tenderness was felt that should have been inflamed cyst at the site of the and absent bowel sounds. A more thoroughly investigated. All original lesion on his chest. It possible mass was palpated in the signs indicated an abscess was treated as an infected cyst right lower quadrant, but not formation, which should have and Mr F was given antibiotics investigated further. He was started been explored at an earlier date and referred to the general on intravenous erythromycin. By before its rupture … had surgical surgical unit the next day to have the third day his urea had risen to exploration been undertaken at an the cyst removed. 20 mmol/l, bilirubin falling to 37. earlier time, his death in all Unfortunately, it transpired His WCC was now 7.3 (87% probability would have been that the lesion was in fact a neutrophils). prevented.’We settled the case for a malignant melanoma. There was The notes say that on the fifth substantial sum. evidence of metastatic spread to day Mr W was ‘doing fine’.His lymph nodes in the axilla, and WCC climbed to 12.6, and his Commentt more distantly, confirmed by a fever persisted. On day six, WCC The decision-making processes of CT scan. Despite treatment, Mr was 20.5. By day seven, Mr W was the team in question appear to F died two years later. recorded as suffering from severe have been seriously impaired, An action against Dr N abdominal pain, but the leading to an avoidable death, alleged sub-standard clinical examination records a soft caused by unnecessarily delayed management for cauterising a abdomen with no mass. The WCC surgery. The website of The pigmented lesion which, it was had risen to 23.3 (89% National Confidential Enquiry claimed, was known to have neutrophils). into Perioperative Deaths bled. According to experts we Over the next five days there is (NCEPOD) contains useful consulted, the lesion should malignant. I therefore believe no record of Mr W’s temperature. information for surgical teams not have been excised with a margin that all GPs who carry out For two of the days there is no wishing to fall prey to the same and sent for histological minor surgery should send all record of clinical review, but the errors. Its document ‘Functioning analysis, rather than cauterised. lesions removed for histology.’ nursing notes do indicate visits by as a team?’ can be viewed at One expert commented, ‘It has The case was settled, and an the surgical team. Mr B, consultant www.ncepod.org. uk/2002.htm. The certainly been the case in the award made on the basis that Mr surgeon, returned from leave and section ‘Decision-Making and past that lesions sent down with F’s chances of 10-year survival of repeated the ultrasound scan, Surgery’ is particularly pertinent to a benign diagnosis have been his melanoma had been reduced which showed possible intra- this case. found on histology to be from about 50% when initially

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Case reports

Failure to recognise received adrenaline, atropine and post-op complication defibrillation. She was transferred to the recovery room, resuscitation kin lesions with care Post-operative continuing during the transfer. Wellcome Photo Library hypotension On arrival in recovery Mrs T regained cardiac output and some Mrs T, a 36-year-old mother of two respiratory effort. She remained young children, attended as an hypotensive and had a heart rate of inpatient for an elective vaginal 130 bpm. Dr J was unsuccessful in hysterectomy and repair of prolapse. attempting central venous and She had no relevant past history and peripheral arterial cannulation. her preoperative assessment was Another anaesthetic consultant, Dr unremarkable. During surgery, Q, was able to insert a Swan-Ganz blood loss was greater than usual at cannula and commence rapid 800 ml but no other problems were transfusion. An enquiry into the noted. In the recovery room she was possibility of coagulopathy was well but noted to be pale and made at this stage, but laboratory agitated, complaining of abdominal confirmation of this only became pain. She received patient-controlled available later. The patient did not opiate analgesia. respond well to the rapid transfusion She was returned to the ward just so an infusion of adrenaline was under an hour after surgery, but started and there was a moderate nursing staff called the anaesthetics improvement in her vital signs. registrar, Dr E, an hour later as she The team planned to move Mrs T had become unwell, pale and to the ITU of a nearby hospital and hypotensive with a borderline to give fresh frozen plasma once bradycardia (BP 100/60 mm Hg, clotting results were known. pulse 52 bpm). Dr E prescribed 40% Haematological and biochemical oxygen and 500 ml of colloid fluid results showed a severe coagulopathy over an hour. with no obvious bleeding. A vaginal A failed attempt to take venous examination revealed no blood was abandoned by her haematoma or other abnormality, gynaecology registrar, Dr K, who and a chest x-ray was reported as called for Dr E to assist him. Dr E normal. The fresh frozen plasma was noted that the patient’s vital signs instituted but during the transfusion were unchanged but her veins were Mrs T had a fit, developed collapsed. He asked the nurse in bradycardia and cardiac arrest. She charge to give Mrs T one unit of did not respond to attempts to whole blood over the next hour and resuscitate her. to transfuse another unit of blood At autopsy, the cause of death was over the following four hours. Dr E given as ‘haemorrhagic shock due to reviewed the patient several times an intra-abdominal haemorrhage over the next few hours. from pelvic operative site following Two hours after the blood hysterectomy and vaginal repair for transfusion had been started, Mrs T uterine prolapse.’ had a BP of 95/55 mm Hg and a Mrs T’s family brought a claim for heart rate of 52 bpm. A urinary compensation and we asked an seen, to about 15% when the after excision with a margin. output of 100 ml since surgery was expert in anaesthetics for his opinion. diagnosis was finally made. Any pigmented skin lesion for recorded. Dr E conferred with his He concluded that the doctors could excision, regardless of how long it consultant, Dr J, and they decided to be criticised for failing to appreciate Commentt is purported to have been present, return Mrs T to the recovery room that hypovolaemia was the cause of Skin cancers can present with a should be treated as a potential to put her on a monitor and insert a Mrs T’s hypotension, and for not variety of atypical appearances, melanoma. This is especially true CVP line. Before they could do this, taking earlier, more aggressive making diagnosis difficult. As this if the lesion has bled, crusted, however, the patient collapsed and measures to locate the site of the case demonstrates, it is wise to been itchy or developed satellite stopped breathing. During bleeding and initiate surgical repair. obtain a histological diagnosis lesions. resuscitation she was intubated and He said,‘Significant intra-abdominal Continued on page 21

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Case reports

Unwitting use of unlicensed medical product The downside of luscious In the early 1990s Ms H wanted plumper lips and consulted Mr M, a cosmetic surgeon, who recommended silicone and collagen injections. After having three collagen injections over three months, she complained that the effect was too short-lived. Dr M suggested that she try silicone oil injections instead and she agreed. Over the next 11 months, Ms H’s lips were injected four times with silicone oil. These treatments were all well documented by Dr M, who kept excellent records of all patient encounters. During the course of treatment, Ms H suffered an itching rash diagnosed as pityriasis rosea. In her subsequent claim against Mr M she described fatigue, disturbed sleep, malaise, back pain, nausea, blurred vision, slurred speech, disorientation and tremor of her trunk. She attributed these symptoms to the course of silicone oil injections. About four years later Ms H suffered neurological symptoms and was diagnosed as having benign, non-progressive multiple sclerosis. Later that year she was diagnosed as suffering from Raynaud’s phenomenon. Ms H later became aware of the potential controversial association between the use of silicone in breast implants and and kept careful records. They the issue, there was no proven this, and had thought that the some connective tissue diseases, were satisfied with the quality of association between silicone use product was a bona fide medical- particularly discussed in the USA. lip augmentation produced by the and multiple sclerosis. grade oil. Because of this we She alleged that Mr M had been procedures. Ms H’s counsel accepted the agreed to pay Ms H £5,000 as negligent in using silicone Our lawyers, supported by argument and agreed that the compensation for a small period injections despite the known risks experts in epidemiology and claim should not proceed on that of pain and suffering. of its use, which had led to her rheumatology, vigorously basis. However, it transpired that subsequent episodes of ill health. contested the unproven the silicone oil Mr M had been Commentt The experts we consulted were association between silicone use using was not licensed as a • Mr M’s defence was greatly aided supportive of Mr M; he had and Ms H’s illnesses. Although medicinal agent at that time in by the quality of his notes. carried out the procedures there has, in recent years, been the UK. • Clinical negligence claims are according to standard practice much controversy surrounding Mr M had not been aware of often brought years after the

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Case reports

Continued from page 19 bleeding must be the number one A was seen by the oral surgeon, Mr Q, Keeping a record of intended referrals differential diagnosis of sustained within two weeks. during a surgery could help to prevent postoperative hypotension, in the The lump was duly excised and a such omissions. Some doctors dictate absence of other differential diagnoses tissue diagnosis of acinic carcinoma referral letters as they go along, with lips such as sepsis, anaphylaxis and made. This required further surgery, the patients in the room. myocardial depression.’The claim was somewhat radical, involving bone • This case demonstrates the important www.photos.com settled for a substantial sum. grafting from the hip. Unfortunately difference between liability – a breach this graft became infected, causing of a duty of care – and causation, i.e. Commentt significant pain and disfigurement to any injury suffered by the claimant as Sustained clinical indicators of Mrs A and necessitating further surgery. a result of the breach of duty. Both of hypovolaemia must not be ignored in a Mrs A issued a legal action against these must be established for a postoperative patient. Following Dr P,alleging negligence for failing to claimant to be eligible for surgery, in a scenario such as this, loss make a timely referral. It was obvious compensation. of blood at the operation site must be that Dr P was liable for her error in excluded, as early as possible, as the failing to refer Mrs A, and on this Techniques and monitoring cause of the patient’s symptoms and basis we made a small payment into signs, in order to avoid tragedy. court to cover Mrs A’s claim for five Infusion risks months of pain and suffering. Mrs B was in her late fifties; she had Administrative error However, expert maxillofacial- been treated surgically for breast surgical advice was that this rare cancer and was to undertake a course Forgotten specialist tumour was low grade and unlikely of adjuvant chemotherapy and referral to have grown significantly in the radiotherapy. When she attended for Mrs A suffered with depression and period between its detection and her first course of chemotherapy, she was seeing her GP,Dr P.During a excision. It was considered that the was given an infusion of consultation to review the efficacy of delay wouldn’t have materially anthracycline. This was set up by Dr her lofepramine, Mrs A mentioned affected the treatment given, or the P, S HO in oncology, using a butterfly that she’d had a lump on the side of outcome. As much of the misfortune needle in the dorsum of the left hand, her face for a long time. Dr P suffered by Mrs A was due to the and checked by the oncology examined Mrs A’s face and noted the postoperative infection, we argued consultant, Dr V. presence of a mobile, 1 cm diameter that causation was not established. The patient was placed in a side lump over the left mandible. Dr P There was conflicting expert room and left alone. No-one came to intended to refer Mrs A to her local opinion that, although the delay monitor the state of the infusion and oral surgery service for advice. probably didn’t affect survival, it may infusion site.After two hours Mrs B Unfortunately, she forgot to dictate have worsened morbidity. This was called for assistance because her left the referral letter at the end of the due to a purported need for more hand had swollen at the site of the surgery. extensive extra-oral (rather than infusion. The infusion was stopped Dr P’s normal practice was to tell intra-oral) surgery and an increased and Dr P was called. She found the patients to contact her if they had not chance of the complications that dorsum of Mrs B’s left hand to be red heard about a referral once a month ensued. We conceded this point and and swollen and ordered a glycerin/ had passed. Mrs A had several further increased our offered payment to the ichthammol dressing. Mrs B was appointments at the surgery over the client, but the offer was refused. discharged from hospital the next day. next few weeks, but failed to attend The case proceeded to trial, where Mrs B suffered serious sequelae any of them. She eventually came to Mr Q testified that, in his opinion, the from this extravasation incident. She see Dr P to discuss other matters, four delay had not affected his approach to required surgical debridement of the alleged negligent incident. months after the first consultation the surgery, or the outcome for Mrs area, when it ulcerated and became Regardless of the current state of about the lump. The lump, and its A. The judgment went against Mrs A, infected three months after the knowledge or beliefs, the claim can assessment by the oral surgeons, who received our original offer, but incident. The skin eventually healed only be judged according to what didn’t come up in the consultation. was not able to recoup legal costs, due but was tight, and there was damage was commonly accepted practice A month later, Mrs A was at the to her rejection of a reasonable offer to her extensor tendons, significantly at the time of the incident. surgery again and saw Dr C. She of compensation for her pain and impairing hand function. • MPS indemnity for cosmetic mentioned that she’d heard nothing suffering. An action against the hospital and surgery varies, depending on the from the oral surgeons. Dr C left Mrs Dr V was launched. The experts we procedure. We advise members to A’s notes out for Dr P,with a note Commentt consulted were very critical of the ensure we are fully informed of explaining the lack of an oral surgical • It’s easy for a busy doctor to forget to following aspects of management: the nature of procedures they opinion. Dr P realised her error and complete an intended specialist • The dorsum of the hand was a poor carry out. dictated the referral shortly after. Mrs referral, due to pressure of time. choice of site. Continued on page 22

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Case reports

Continued from page 21 Consent – warning about complications • Using a needle instead of a flexible variety of topical and systemic radiologist. This proved to be critical cannula was inherently dangerous NSAID preparations, but without of the diagnostic radiologist who and increased the risk of any discernible benefit. failed to notice the lesion in the extravasation. At one point he saw a locum who acromion. Orthopaedic experts were • The nursing staff’s monitoring of requested an x-ray of his shoulders, also critical of Mr O. the progress of the infusion was which was reported as normal. Mr His decision to order non-urgent inadequate, and Mrs B’s placement W remained troubled by his investigations compounded the in a side ward was inappropriate. symptoms and saw Dr J at least once delay. They thought that he should, • No attempt was made to aspirate a month over the next six months. at the least, have arranged for excess solution from the dorsum of By now the pain was affecting his baseline bloods and an urgent bone the hand after the incident. left shoulder and he was scan. He might also have usefully • Subcutaneous hydrocortisone experiencing pins and needles in his arranged for a radiologically guided should have been administered to left arm. Dr J referred Mr W for biopsy of the lesion to establish a the affected area following physiotherapy. Two months of heat, histological diagnosis. According to the incident. mobilisation and ultrasound resulted an expert in haemotology, if this had The case was indefensible and in only a slight improvement in joint been done, and treatment initiated settled for a significant sum, liability mobility and pain relief. immediately, it was likely that Mr W being shared with the hospital’s Dr J referred Mr W to a local would never have developed insurers. orthopaedic surgeon, Mr O, for paraplegia and its sequelae. advice. Mr O noted a history of We contributed a small sum on Commentt right-shoulder pain, on and off for behalf of Dr J to settle this action. • The extravasation of irritant two years, and found some local The hospital responsible for the solutions, causing damage to tenderness over the right acromion. x-rays and the orthopaedic adjacent tissues, accounts for several A repeat x-ray showed a lytic lesion consultation paid the remainder of a claims against MPS members each within the right acromion. Mr O substantial settlement. year. compared this to the old x-ray and • Cytotoxic infusions should always be noticed that it had been present all Successful defence administered with great care, and along, despite the x-ray being preferably by an experienced, trained reported as normal. Mr O arranged a Maybe malaria? and dedicated team who will know non-urgent CT scan of the thorax. Before going on holiday to Kenya, how to act appropriately should an Unfortunately, about six weeks Mr A visited his GP’s surgery where extravasation incident occur. after seeing Mr O, Mr W developed he saw nurse J for advice on travel • Any infusion containing an irritant paraplegia and was admitted to prophylaxis. She documented his drug given into the dorsum of the hospital for urgent investigation. previous immunisations and gave hand requires careful and close It transpired that he had tetanus and polio boosters, noting monitoring. D compression of his thoracic spinal that he already had some malaria elayed diagnosis cord, due to multiple myeloma. Mr prophylaxis tablets. The dosage Delayed diagnosis W had surgical debulking and regimen and type of tablets were not received chemotherapy. He recorded. A short while after Shouldering recovered from the paraplegia but returning from his trip, Mr A was responsibility was left with some neurological unwell. He saw his GP,Dr C, and Mr W was a young dad with a wife disability. His myeloma recurred and gave symptoms of shivering, and two small children. He developed he eventually needed an allogeneic diarrhoea and bilateral back pain pain in his neck and right shoulder bone-marrow transplant. radiating to the lower abdomen. Dr and consulted his GP,Dr J. Finding An action was launched against C thoroughly examined Mr A and some slight tenderness over the right Dr J, alleging that his delay in found only pyrexia, without specific shoulder with a full range of move- referring Mr W to hospital had been clinical signs. Working on a diagnosis ment, Dr J prescribed ibuprofen. negligent. GP experts criticised him of gastroenteritis, Dr C Mr W attended the practice on for persisting with ineffective recommended plenty of fluids and many occasions over the next year, medication and physiotherapy temperature-control methods. chiefly with right-shoulder pain, but without seeking an alternative Four days later, Dr C spoke to also with episodes of back and neck diagnosis. They accepted, however, Mr A by phone. Mr A told him that pain. He saw other members of the that he had been misled by the his temperature was still up, he was practice, and the working diagnosis normal x-ray report, which had constantly thirsty, sometimes seems to have been muscular pain or made his job more difficult. confused and still vomiting. Dr C ‘mechanical backache’.He received a We sought advice from a visited Mr A at his home and Continued on page 25

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Case reports

ations Duty to warn In the mid 1990s, Mr L presented wise to warn patients of to hospital following a potential damage to the sural spontaneous rupture of his left nerve using the percutaneous Achilles tendon. Mr C, consultant technique. orthopaedic surgeon, performed One expert noted,‘It is clear a percutaneous repair of the that, while the percutaneous tendon, following which the technique is well established tendon appeared to heal well. and very acceptable, the main At a follow-up consultation complication … is damage to four months later, Mr L told Mr the sural nerve, and several C that he was experiencing researchers have adopted numbness and discomfort modifications specifically to affecting the lateral skin of his left avoid this … the incidence leg and heel. Six months after the suggests that it is uncommon injury, Mr L was becoming but not rare in most people’s increasingly concerned by the hands.’ numbness and paraesthesiae. Mr We decided to settle the C suspected sural nerve injury as claim for a moderate sum, on the cause and referred Mr L to his the basis that Mr L should have colleague, Mr R, a consultant been warned of the potential plastic surgeon. Mr R explored risks before consenting to the the sural nerve and found it procedure. transfixed by a suture, with an accompanying neuroma, Commentt requiring reconstructive repair. • Recent research – Lim J, Dalal Mr L alleged that his sural- R, Waseem M. Percutaneous vs. nerve damage caused him Open Repair Of The Ruptured ongoing discomfort, hampered Achilles Tendon: A Prospective his mobility and left him prone to Randomised Controlled Study. neuropathic damage of his foot. Foot Ankle Int (2001) 22(7): Proceedings against Mr C alleged 559–68 – suggests that negligence in failing to identify the picture is not so clear when and isolate the sural nerve during using a modified percutaneous the operation. technique. Lim et al. reported a We sought the advice of low rate of sural nerve damage orthopaedic experts, who in a small series of cases, and reported as follows: The some distinct outcome technique of percutaneous advantages, compared to the repair of the Achilles tendon open technique. was first described in 1977 by • If using an alternative Ma and Griffith. Previous technique to treat a particular research had shown that it carried problem, it is important to be a significantly higher fully aware of how it may differ risk of sural nerve damage from a more common method, than the more common in terms of outcome and technique of open repair (17% complications. Patients must be in one series, compared to informed of how the risk of a about 2% for the open certain complication differs, if technique). it differs significantly, when Given these research findings, compared to standard the experts felt that it would be technique.

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Case reports

Failure to recognise post-op complication A tight situation

Mrs W, a retired lady in her seventies, had suffered from a painful and stiff left knee for some years. She saw an orthopaedic surgeon, Mr D, who recommended a left total-knee replacement. Mr D had some trouble operating on Mrs W’s knee. He had to use a substantial medial release procedure, stripping the entire postero-medial aspect of the tibia. Mr D applied a tourniquet around the left thigh to aid haemostasis. This was in place for 2 hours and 10 minutes. This time reflects the degree of difficulty Mr D had during surgery. The notes show that Mrs W’s left foot turned pink on release of the tourniquet. Mrs W’s postoperative care included a regional epidural infusion for analgesia. In the early postoperative period, Mrs W’s left foot was pale and pulseless with poor sensation. A performed an immediate Treatment after the diagnosis of to be liable, in that he saw the little later it seemed pinker, but fasciotomy, leaving the wounds compartment syndrome was patient only once, and gave advice sensation remained impaired. Two open, and giving the patient IV deemed timely and appropriate. appropriate to the clinical situation days after the operation it was cool antibiotics. Mrs W needed larval The tourniquet time was held to be at that time. to the touch, numb and poorly (maggot) therapy to treat her at the upper end of the acceptable perfused. Mr R, consultant vascular healing wounds, an experience she limit used by a responsible body of Commentt surgeon, came to see Mrs W, at her didn’t relish. orthopaedic surgeons. The use of a tourniquet during team’s request. Mr R suggested Mrs W had significant sequelae The question of liability centred orthopaedic surgery is not universal. some investigations, although the from her compartment syndrome. on the speed with which diagnoses When gaining consent from patients notes do not show that these were Although the vascular and nerve were made. One expert for a procedure where one will be carried out. supplies to her foot were intact, she commented,‘ … there does appear used, it may be wise to give details of Later that day, Mrs W was had marked muscle necrosis. Mrs to have been a period of about three its use and the potential effects this reviewed by her orthopaedic team. W was left with a disabling left- days during which the muscle could have. The notes show that the foot was sided foot drop. She launched a damage developed, and I am afraid Compartment syndrome is an pinker, but couldn’t be actively legal action against Mr J, alleging that the impression given by the extremely time-sensitive clinical dorsiflexed at the ankle. The team negligence in the management of clinical notes … is one of problem. To prevent significant diagnosed neuropraxia of the left her postoperative vascular indecisiveness and uncertainty. adverse long-term effects, it must be sciatic nerve. Mrs W was not doing problems. ‘It should, I think, have been remedied early in its course. so well the next day. Her left calf There was some debate amongst clear that a serious complication Its pathognomonic features was intensely painful and hard. the orthopaedic and vascular was arising, and even though the include: Passive dorsiflexion of the ankle experts we consulted. On the clinical picture was variable and • Pain disproportionate to the clinical caused severe muscle pain. Mr J balance of probabilities, it was partially masked by the analgesia situation arranged pressure gauging of the thought that ischaemic damage due (epidural infusion), I believe that • Pain on passive stretching of the leg compartments, suspecting a to prolonged use of the tourniquet, the diagnosis should have been involved muscles diagnosis of compartment followed by a reperfusion-related made sooner.’ • Disturbed skin sensation, in the syndrome. This proved to be the compartment syndrome, was the The case was settled for a distribution served by nerves cause of the problem. Mr J most likely clinical scenario. moderate sum. Mr R was not held traversing the compartment.

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Case reports

Continued from page 22 found a persistent pyrexia, such. It concerned the history of Mr nurse J and Dr C, and concerned the • When taking details of medication, it tachycardia, tachypnoea and A having taken malarial prophylaxis. failure to fully elucidate the nature is important to record exactly what is borderline hypotension, with signs Dr C documented the date of entry and suitability of the malaria being taken, the dose and its consistent with consolidation at the and the date of finding out about the prophylaxis used. However, he frequency. right lung base. Dr C’s differential prophylactic medication. Once again, considered the rest of Dr C’s actions • Malaria prophylaxis is a complex and diagnosis was pneumonia and/or however, the exact nature of the as good, reasonable practice. The rapidly changing area of knowledge. It malaria, prompting him to refer Mr prophylaxis taken wasn’t detailed. claim from Mr A was abandoned at is important to use up-to-date A urgently to his local general Mr A lodged proceedings against Dr trial, as the deficiencies he alleged reference sources to decide on the medical team. Mr A needed to be C, alleging negligence in that he had were not supported by expert appropriate prophylactic regimen, for admitted to ITU for ventilatory diagnosed gastroenteritis on the first opinion. travellers to any particular area. In support; the diagnosis was visit. Mr A also alleged that Dr C should the UK the Public Health Laboratory confirmed as malaria with have visited, diagnosed and treated him Commentt Service website at www.phls.co.uk secondary pneumonia. earlier in the four-day period. He • The quality of Dr C’s notekeeping contains relevant guidelines and Dr C’s records were of a high alleged long-term psychiatric problems made this action relatively easy to lists of local resources to contact for standard. He had noted all relevant as a result of his malaria. defend. advice. findings and important negative We sought the opinion of a GP • A retrospective note is acceptable in • Assuming that old medication from ones. He did make one retrospective expert,who had only one criticism of clinical records, as long as it is clearly previous trips will be adequate is a note, but this was clearly marked as Mr A’s treatment. This was directed at marked as such. risky strategy.

A valuable addition to a practice library Promoting child health in problems), the dynamics of the implementation process is safe in provide a basic primary care family and how best to contribute to practice. overview of Edited by Anthony Harden and Aziz the welfare and wellbeing of the Training requirements are referred clinical Sheikh growing and developing individual. to on several occasions, reinforcing negligence, Royal College of General Practitioners Importantly, the book includes the need for evidence-based practice consent, child £21.50 chapters on medico-legal aspects of and consistent approaches.‘GPs and protection ISBN 085084 2824 child health surveillance and child other members of the primary care and clinical Reviewed by Jane Cowan protection. team should have a working documentation. There is little The roles of clinical risk knowledge of the key recom- reference elsewhere in the book to In the foreword to this book, management and clinical governance mendations and the management of the importance of maintaining Professor Dame Lesley Southgate in child health in the modern the common problems, to help good-quality documentation or the comments that, in the past, input primary care team are missing. This ensure parents are given advice that is role of the personal child health from the general practitioner ‘has was perhaps intentional, but progress evidence-based and consistent’.This record.Indeed, accountability for often been separate from, and in the provision of healthcare of is reaffirmed in the chapter on child clinical decision-making and the sometimes at cross-purposes with, necessity includes these aspects. protection as follows:‘GPs are under need for supportable practice are that of other health and social work Some of the important comments obligation to address their personal rarely dealt with as a concept; professionals’.The aims of the book, on safe practice – evaluating process training needs in matters relating to perhaps this may have been assumed therefore, are to promote the and developing standards – are at child protection.’ by the contributors. primary role of the parents in the times lost in the text and may have Given the publication of Lord The book would make a valuable care of their children, encourage benefited from greater emphasis. Laming’s report into the death of addition to a practice library. Each those working in primary care to Examples include the chapter on Victoria Climbié in January of this chapter is sufficiently well contained consider the importance of childhood immunisation, which is year, the advice provided is valuable to deal with areas of interest. GP multiprofessional working and to well written and contains a great deal and indeed very relevant. The ten registrars in particular would do well reflect on current changes in practice. of information about vaccines, common pitfalls that the authors list to familiarise themselves with this To a great extent the book achieves including some historical are worthy of consideration by all book. Taken in conjunction with the this. The 11 chapters cover a range of perspectives. Whilst the organisation practitioners in the primary-care new Hall report (4th edition) and the different topics, some in greater of a vaccination clinic is dealt with, team. recommendations for health in the depth than others, providing insight more emphasis on the safe running The chapter on child protection Laming report (see www.victoria- into many of the problems that the of vaccination programmes within then leads into a chapter on the climbie-inquiry.org.uk GP has to deal with. This includes the primary care would perhaps have medico-legal aspects of child health /finreport/finreport.htm), the GP management of the child been valuable. Parents are given surveillance, the content being should be well equipped to address (apparently, 30% of consultations are opportunities to make informed broader than the title suggests. parental and professional concerns in related to emotional and behavioural choices but should expect that the Various topics are addressed and many aspects of child health.

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Letters

Letters

Smooth v Africa are achieving very satisfactory results with smooth implants. Antibiotic prophylaxis and updated guidance on this issue, Dr Thomas D Ford and I would commend this textured breast Plastic and reconstructive surgeon, Dear Editor, information to your readers. In the Sandton, South Africa I feel I should write to make two UK at present, had the decision been implants comments about the case report in made to give antibiotic cover, the Dear Editor, Our decision to settle was based on the Casebook June 2003, titled ‘Is choice in this case would probably I read the March 2003 edition of MPS opinions of two experts in plastic arthroscopy a sterile procedure?’ have been oral clindamycin or Casebook,and was surprised that you surgery in the United Kingdom (where If, as stated, there was a letter in the azithromycin. had accepted an expert opinion that this operation took place). patient’s notes recommending the Name and address supplied smooth implants were outdated and They referred to a report from the use of antibiotic prophylaxis for oral inferior to rough, textured implants. Independent Review Group on silicone or GU instrumentation, it must be This case occurred in the UK in 1988, Smooth implants are usually placed gel breast implants, published in July assumed, at pre-operative and guidelines available at the time behind the muscle, whereas rough 1998, which noted that gel bleed and assessment, that a potential recommended the use of erythromycin implants are placed in front. The contracture rates were lower with endocardial defect is still present.A where penicillins weren’t suitable, due placement of implants behind muscle textured implants, compared to earlier review of the previous medical notes to a reported allergy. The allergy means that the pectoralis muscles are implants. should be a routine part of the would appear to have been a red continually massaging the implant, One expert referred to figures anaesthetic assessment and guides herring, as the patient was eventually compressing it, displacing its volume published by Grabbe and Smith in potential questioning of patient and treated with flucloxacillin – we have no and pushing away any scar that might 2000, which showed that smooth family. This information should then information on this, as it wasn’t try to encapsulate and constrict it. implants have a contracture rate of lead to an informed decision with the relevant to the claim, and we can only This has probably done more to between 40% and 60%, while textured surgical and, possibly, cardiology assume that the nature of the allergy prevent capsular contracture than the implants have a contracture rate of teams, as to whether prophylaxis is was elucidated and thought to be advent of rough textured implants about 10%. Both experts asserted that appropriate. This decision should, of insignificant. As this correspondent and has done. only a very small minority of surgeons course, be discussed with the patient another reader, Dr David Mitchell I would be grateful if you would in the United Kingdom would still use and fully documented. from Ireland, have pointed out, this discuss the scientific evidence that smooth implants as most had been As regards the choice of guidance has now been superseded, disputes this point of view, as a large using textured implants since the late antibiotics, you do not state when or and we endorse the recommendation number of our membership in South 1980s. where this case occurred, and it is to use a national formulary. Where therefore difficult to decide on the time-sensitive guidance occurs in our Corneal damage prone position on a neurosurgical appropriateness or otherwise of the report, we do usually try to give the headring, which slipped onto an eye choices made. However, for some date to avoid confusion. We are sorry if and anaesthesia shield.Artificial eye protection should years now, the British National our failure to do so in this instance has Dear Editor, be used only when necessary. Formulary has published referenced misled any readers. I must vigorously protest your Dr KN Williams conclusions from the case of corneal Consultant Anaesthetist, who are successful in removing the Consultant Interventional damage (possibly) sustained under St Thomas’ Hospital, London. majority of IUCDs. If the IUCD is Radiologists, Royal Berkshire and anaesthesia.You appear to say that unretrievable at such a clinic, then the Battle NHS Hospitals Trust artificial eye protection must be Our comments attached to the case patient should have an ultrasound References applied universally.I was taught never report, and referred to by Dr Williams, scan to ascertain whether the IUCD is Gibson M and Torrie EPH. to say ‘always’ and never to say ‘never’. were written to emphasise that eye care within the uterus. If it is not seen Fluoroscopically controlled removal Despite, or perhaps because of, an for patients under anaesthesia should within the uterus, an x-ray of the of intrauterine contraceptive devices. extensive practice in ophthalmic be considered, conducted appropriately pelvis should be taken to see if the Clinical Radiology (1996) 51:654–655. anaesthesia, I also disagree that any and documented. The actual IUCD has migrated to the pelvic artificial fabric or substance be protection used, be it physical, cavity. If so, then a CT should be Drs Torrie and Gibson raise a number applied to, or near, the eye without a pharmacological or positional, should performed to identify the exact of important points in their letter. In clear clinical indication; these, in my be appropriate to the procedure and location of the IUCD. addition, as a matter of good practice, opinion are relatively few e.g. prone patient, and in line with accepted Finally, most patients with IUCDs once it has been established by clinical position, head towels, etc. Under current guidelines. that are in the uterus, but not examination and ultrasound that the anaesthesia the best protection for the retrievable by conventional means, IUCD is not in the uterine cavity, a eye is a closed upper eyelid and should be referred to an pregnancy test would be a wise repeated careful observation by the Lost IUCDs interventional radiologist, who will, precaution. This would exclude a very anaesthetist. Dear Editor, under fluoroscopic control, and as an early pregnancy before exposure to In training I observed (yet Re:The case report in Casebook, out-patient, remove the IUCD ionising radiation, particularly where thankfully was not involved in) a March 2003, concerning a lost coil. successfully. Thus patients do not CT scanning is contemplated. Clearly, it corneal transplant following four This article raises other points need to be referred to a gynaecologist is preferable if a general anesthetic can hours of micropore tape adhering to regarding lost IUCDs. Firstly, a for this procedure and ceratinly do be avoided. However, fluoroscopic a cornea, and blindness after a retinal patient who has a lost IUCD should not need a general anaesthetic. retrieval is dependent on the availabilty artery occlusion during six hours be sent to a family planning clinic, Drs EPH Torrie & M Gibson, of the necessary radiological expertise.

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What we can do for you Contacts What we can do for you As a member, you can ask MPS for independent confidential advice on a wide range of medico-legal and ethical issues as often as you need to.

MPS is a mutual society providing membership How to contact us benefits on a discretionary basis. Members do not make a claim on an insurance policy, but instead For questions about your MPS membership (subscriptions, etc.) apply to MPS for assistance. Decisions on whether You can make enquiries about joining MPS, or about your subscription rates and payments, or not to assist are made by fellow healthcare by calling the Membership Helpline: professionals applying criteria developed through Tel: 0845 718 7187 long experience and with a bias to assist. Benefits of Fax: 0113 241 0500 membership include: Students’ helpline: 0845 900 0022 Email: [email protected] 1. Complete, occurrence-based indemnity Typically, a negligence claim will be made two or For medico-legal advice three years after the incident that gave rise to it, In an emergency, you can call us for advice and assistance at any time. For non-urgent calls, which is why MPS indemnity is occurrence however, we ask that you ring within normal office hours. based. Tel: 0845 605 4000 Fax: 0113 241 0500 2. Legal representation You can also email MPS direct at [email protected] – please remember, though, that this is not MPS provides first-class specialist legal advice and representation across the full range of MPS a secure method of transmission, so patient-identifiable information should not be included in benefits of membership, including clinical an email. negligence claims and disciplinary hearings. Services for GPs Tel: 0113 241 0507 3. 24-hour telephone advice Fax: 0113 241 0500 Each year we take about 20,000 calls from members seeking help in resolving specific ethical Email: [email protected] and medico-legal dilemmas as they arise in Services for students everyday practice. Tel: 0113 241 0634 Fax: 0113 241 0500 4. Media relations Email: [email protected] If you are unfortunate enough to be involved in a case that attracts adverse publicity, we will help To order publications you prepare statements to the press and shield Tel: 0113 241 0354 you from press intrusions as far as is possible by Fax: 0113 241 0500 acting as your spokesperson. Email: [email protected]

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