A 52-year old woman was admitted for a partial thyroidectomy. During her pre-operative assessment she was told about the risks associated with thyroid surgery, including nerve damage and parathyroid gland damage. Her vocal fold mobility was confirmed pre-operatively. During the operation a voluminous multinodular goitre was found and the recurrent laryngeal nerves positively identified by careful dissection. Surgery appeared at the time to be uneventful, although it was notably more difficult on the right.
Two days after the operation the patient complained of hoarseness and a change in the quality of her voice, described as a squeakiness. Fibreoptic laryngoscopy was carried out, which demonstrated a right-sided vocal cord paresis.
There had been no problems with phonation prior to surgery, and the surgical team concluded that an injury to the right recurrent laryngeal nerve had occurred during surgery. The senior member of the surgical team (who had been assisting and supervising a surgical specialist trainee) met with the patient and explained what had been found, and apologised. The hospital procedure for reporting patient safety incidents and adverse outcomes was followed.
Assessment and subsequent voice therapy from a speech and language therapist followed, and the hospital's management team responsible for the statutory duty of candour promptly considered the report of the injury that had been received. A consultant specialist in endocrine and thyroid surgery who was independent of the team that carried out the surgery advised that the cause of the patient's post-operative symptoms were likely due to the surgery and that this had been an unintended outcome (although the patient had been correctly warned of the risk). The assessment was also that the threshold triggering the statutory duty of candour procedure had been met as the patient would require further treatment to try and improve the hoarseness and quality of her voice.
Assisted by statements from the specialist trainee, consultant and SLT therapist, the manager wrote to the patient with a detailed explanation of what happened, after having initially made contact on the telephone so that the correspondence did not appear to come out of the blue. Although the consultant had offered an apology at the outset, the manager offered a written apology in the letter and explained that further treatment aimed at improving the patient's voice would continue. The doctors involved in the patient's care discussed the case at a morbidity and mortality meeting, reflected on whether any learning points arose from it and in time discussed it at their annual appraisals. An offer of a meeting was made, which the patient did not want, but she did say she would like a copy of the report of the full review that was being undertaken.
Four weeks after the initial notification to the patient, the manager wrote again to the patient with the review. The report summarised what had happened and explained that the case had been discussed within the hospital, to provide further learning. The review had indicated that in fact the surgery had been undertaken competently, that the surgeon was aware of the risk of nerve damage and explained that to the patient prior to surgery, and had not been aware of having caused injury until the patient experienced problems with her voice. The report noted that although no specific learning points had been identified, those surgeons who undertook thyroid surgery would remain especially vigilant where there was to be excision of a large goitre and that all would continue to contribute to national audit processes. A formal apology was included in the report.
Although the patient had initially been contemplating litigation, the open and thorough review process had the effect of persuading her that the standard of care had been reasonable. Within six months her voice was almost normal in its character and the patient by that point was delighted with the result of her surgery.
This guidance was correct at publication 29/03/2018. 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.