CASE studies


These studies are based on actual cases from MDDUS fi les and are published in Summons to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confi dentiality


DIAGNOSIS POST-OP COMPLICATIONS


BACKGROUND: Ms T is 51-year-old HR manager with two teenage children. A recent echocardiogram has revealed progressive ventricular enlargement due to long-standing aortic regurgitation. A cardiothoracic surgeon – Mr A – advises aortic valve replacement and Ms T elects to undergo the procedure privately. Ms T is admitted to hospital and Mr


A replaces her aortic valve with a bileafl et mechanical prosthesis. Routine peri-operative antibiotic prophylaxis is administered IV (fl ucloxacillin) followed by gentamicin eight-hourly for three doses. The operation is routine and Ms T is transferred to the ITU for recovery. Next day the surgeon notes that Ms


T’s vital signs are normal though with a slightly elevated temperature. A few days later Mr A again notes the elevated temperature and orders blood cultures which yield coagulase negative staphylococcus from one bottle in four. This is thought to be a skin contaminant and not sign of infection. Seven days after the operation Ms


T’s temperature is noted at 38.2 and both her CRP and ESR are slightly elevated. Mr A attributes this to pericardiotomy. The next day she is discharged with a follow-up appointment in six weeks. Ten days later Ms T presents at the


local A&E complaining of shortness of breath, tachycardia and severe backache. She is seen by an SHO who notes her history of valve replacement. Ms T reports that she has been unwell since the operation – tired, listless and sweaty with shortness of breath. Her pulse rate regulates and she is found to be apyrexial. She is diagnosed with “panic attack”. Two days later she returns to A&E again with backache and a racing pulse


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and is sent home with a prescription for diazepam to ease anxiety. Next day she returns with worsening symptoms and also nausea and vomiting. She is referred to the physician on-call. Urgent blood tests reveal an elevated white cell count. Septicaemia and possible endocarditis are suspected. Immediate treatment with IV antibiotics is commenced. Transthoracic echocardiography reveals no vegetations but there is severe regurgitation through the prosthetic heart valve. Ms T is transferred to the ITU and


later that night suff ers a fatal cardiac arrest. Four months later both Mr A and the hospital are contacted by solicitors acting for the family of Ms T claiming clinical negligence in her treatment. It is alleged that Mr A was negligent is discharging the patient from the hospital with a positive blood culture and raised CRP and ESR in combination with an intermittently elevated temperature. Suspected infective endocarditis should have been a clear concern.


ANALYSIS/OUTCOME: MDDUS provides support to Mr A in regard to the claim over Ms T’s private treatment. Legal support for the hospital is provided via the NHS. An expert report is commissioned from a professor of cardiac surgery who examines the patient records and other evidence associated with the case. No fault is found in the competence with which the procedure was conducted and with the use of prophylactic antibiotics – though it is acknowledged that infection most likely occurred at the time of the operation. The expert notes there was a positive blood culture in only one of multiple bottles and also confi rms that


elevated CRP, ESR and temperature are not uncommon after open heart surgery. Clinical records show that Mr A had considered the possibility of infective endocarditis and took measures to exclude this diagnosis. Considering all the evidence the


expert concludes that the post- operative management of the patient was reasonable. He does state that in hindsight it might have been prudent to give the patient temperature charts for home use after discharge from hospital with follow-up in two weeks rather than six. Another expert on the case fi nds fault with the treatment Ms T experienced in A&E and concludes that had the prospect of endocarditis been acted upon with onward referral to cardiology and appropriate antibiotics commenced then cardiac arrest could have been averted. Considering all the facts in the case it is decided that there would be risk in taking the case to court. A settlement is negotiated and MDDUS contributes 10 per cent on behalf of Mr A.


KEY POINTS • Have a high index of suspicion in possible post-operative infection.


•


Patient anxiety can mask more serious critical signs.


SUMMONS


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