Emergency laparotomies: why mistakes happen

The First Patient Report of the National Emergency Laparotomy Audit has been published this week.  This is a review of emergency surgery nationwide looking at not only outcomes but also good or not so good practice.

It is clear at the outset that there are some significant failings but pockets of good practice overall.

About 83% of eligible patients were reviewed as part of the process but the findings for some areas are depressingly familiar.

Only half of patients admitted as an emergency and undergoing surgery of this kind were reviewed by a consultant in the first 12 hours of admission. Given that most had surgery in that time it is noteworthy that there are a large number of non-consultants undertaking this type of work.

Those admitted after midnight had better chance of seeing a consultant than those in the evening. In short overall there was still a significant shortage in the number of consultants available at the appropriate time.  There was notably also a shortage of consultant anaesthetists and the combination of not having the two seemed to have an impact on outcome.  However 66% of operations had both present at least some or all of the time either in a supervisory category or dealing direct.  The main issue was once again that out of hours the numbers dropped significantly and only 41% of operations had both consultants present after midnight.

Other issues which were raised were access to theatres particularly at busy hospital periods. A significant minority of patients did not reach theatre within a reasonable time putting them at much greater risk. Critical care facilities were only available for approximately 60% of emergency bowel surgery patients though the recommendation is for cover to be there for all.

These finding mirror quite well the issues which we routinely come across in clinical negligence litigation.  It is not uncommon to find patients who have had surgery of this kind transferred back to a busy ward where staff can be otherwise engaged. In critical care the nurse/patient ratio is 1 :1 or 1:2.  On the wards nurses can deal with 6 or 7 patients some or all of whom can be demanding, have considerable needs or simply be time consuming.

By way of an example I dealt with a case where the client needed emergency surgery on admission for some unexplained abdominal condition. Post-operatively she was transferred to a busy surgical ward where staff were dealing with a number of elderly and confused post-operative patients. Initial checks on her blood pressure and pulse were reasonable if a little chaotic but after a few hours they stopped either due to an emergency on the ward or because of other distractions.  In any event the nursing staff failed to notice the decreasing blood pressure and the rapidly rising pulse.   By the following morning when the client collapsed and had a heart attack she was only successfully resuscitated by the excellent skills of the ICU and cardiac crash teams. She was in ICU for many months and ultimately developed numerous complications for being immobile. Most are permanent and from running a small business she became someone unable to work, being cared for by her children.

There was a failure from nursing staff to see the problem not because they did not have the skills but because they did not have the benefit of proper time to look after the patient.

Likewise the continued issue about out of hours care (both GP and other) means that many emergencies simply do not get the level of care which is appropriate.  All of these types of issues ultimately lead to potential medical negligence claims.

These are life threatening  illnesses which require rapid and experienced input. The consequences other than loss of life can be significant. That can reflect in the value of the claim and sadly the likelihood of it being settled  at a reasonably early stage.

Whilst the media and the government continue to  complain about legal costs in clinical negligence cases, perhaps it would be better if they  paid attention to the numerous reports from differing sources which all indicate that inadequate facilities, poor staff ratios and out of hours problems  leads to poorer outcomes.

This is a  new area to report but these type of cases form a significant part of my caseload.  I can only hope this report enables trusts to identify properly where resources should be directed and to ensure that these particularly challenging areas of medical and surgical practice are properly funded and supported.  Otherwise it simply becomes another depressing report on how the NHS is not adapting to the problems identified in so many reports and medical comments over the years.  That would be  a waste.

* Disclaimer: The information on the Anthony Gold website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. It is provided without any representations or warranties, express or implied.*