Bilateral amputation

The scene

At triage, the nurse noted the patient's knee was hot, swollen and tender. An ST doctor in the A&E department also recorded that, on examination, the knee was swollen and hot. He arranged for an x-ray and excluded bony injury from his diagnosis. The patient was then examined by an ST doctor from the orthopaedic department who additionally noted that the patient was unable to bear weight on the leg.

The doctors agreed the most likely diagnosis was a soft tissue injury and the patient was advised to attend the outpatient clinic the following day, at which time the patient was seen by a registrar who noted on examination that the knee was now markedly swollen and the patient very reluctant to weight-bear. The registrar also considered the cause to be a soft tissue injury.
 
Later that day, the patient contacted her surgery complaining of severe knee pain, vomiting and diarrhoea and requested a home visit by her GP, an MDU member. The member noted the patient's history and that she had been taking powerful analgesia, had not slept for two days and appeared confused. On examination, the member noted that the patient was mildly dehydrated, agitated and appeared drowsy. He also noted a marked knee effusion.

The patient told the GP that she had been seen in hospital and diagnosed with a soft tissue injury. The GP was concerned about her history of persistent vomiting, diarrhoea and clinical signs of dehydration. He also wondered whether the cause of her confusion was the analgesia. The member prescribed alternative analgesia and an anti-emetic, advising the patient to call if there were any further concerns.

Later that day, the patient telephoned the surgery to say that she was still in pain and continuing to vomit. The member advised that the patient should give the new medication time to work.

The patient's condition deteriorated and the following morning, an ambulance was called and she was admitted to hospital. Meningococcal septicaemia was suspected; the patient was administered antibiotics and transferred to ITU. She received intensive management during the course of the next few days. However, despite life saving treatment, she had to undergo bilateral below-knee amputation.

The patient brought a claim against both the hospital trust and the MDU member, alleging negligent failure to diagnose septic arthritis in the knee which led to the development of septicaemia. It was alleged that had the correct diagnosis been made, and with appropriate treatment by the hospital and an urgent referral by the MDU member, the patient would have avoided amputation.

The outcome

 

The MDU obtained independent expert opinions from two general practitioners, both of whom were critical of the member's management. One expert felt that, regardless of whether or not the member should have considered a diagnosis of septic arthritis, the patient should have been admitted to hospital given her history of confusion, persistent diarrhoea and vomiting and clinically detectable dehydration.

The second GP expert went further, saying that the member should have considered the possibility of septic arthritis and made an urgent hospital referral.

The MDU also obtained expert evidence on the orthopaedic management in hospital. The MDU's expert was highly critical of the diagnosis of soft tissue injury.

A microbiology expert instructed by the MDU considered that if the patient had been appropriately managed in hospital following her attendance at A&E and the orthopaedic clinic, it was likely that she would have avoided amputation. However, the expert advised that by the time the MDU member became involved in the case, it was unlikely that admission to hospital and instigation of earlier treatment would have prevented the outcome.
 
In the light of the opinions of the two GP experts, the member consented to the MDU making an admission of breach of duty of care on his behalf. The member acknowledged that he should have admitted the patient, even though he had been to some extent reassured by the fact that she had been seen in hospital earlier that day. With the consent of the member, the MDU decided to enter into settlement negotiations with the claimant's solicitors on the basis that the Trust contributed towards any settlement.

The claim was settled and the larger share of the damages paid by the Trust. Damages were agreed at £1.5m, plus payment of legal costs.
 

This guidance was correct at publication 17/12/2010. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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