Unidentifiable abdominal bleeding

A 61-year old male patient was diagnosed with diverticulitis. Surgery was considered but deferred because he had commitments abroad.  While out of the country, his colon perforated; he underwent surgery and was given a colostomy. Following his return to the UK another surgeon reversed the colostomy but post-operative difficulties resulted in peritonitis and required re-formation of a stoma.

Several months later the patient sought advice from a colorectal surgeon, an expert in this field, who agreed to try to reverse the colostomy. 

The patient's post-operative progress was satisfactory until the second day after surgery when he experienced nausea and increasing pain. The clinical staff identified that the epidural cannula had become dislodged and this was re-sited. The patient's condition stabilised but some hours later he again complained of increasing pain; he had a cardiac arrest and following a difficult resuscitation he was returned to theatre for an exploratory procedure. 

The patient was bleeding internally but despite an exhaustive search by the colorectal surgeon and his experienced specialist registrar, the source of the bleeding could not be identified. The abdomen was packed and in the early hours of the morning the patient was returned to ICU with a view to possible further surgery later that day. However, his condition did not improve sufficiently to permit further surgery and he died the following day.

The post-mortem report showed multi-organ failure, intra-abdominal haemorrhage and infarcted bowel due to band adhesions proximal to the ileostomy. The pathologist could not identify the site of the bleeding.

The patient's widow brought a claim. The main allegation was that the surgeon had failed to divide an adhesion that was trapping the bowel at the time of decommissioning the colostomy and fashioning an ileostomy, and again when trying to identify the source of internal bleeding. Allegations were also made against the trust for failing to have sufficient experienced staff on duty. Much was made about the increasing complaint of pain and nausea on the day leading up to the cardiac arrest but it was clear from the records that the epidural catheter had come adrift, upsetting the pain control at this time.

The patient was bleeding internally but despite an exhaustive search by the colorectal surgeon and his experienced specialist registrar, the source of the bleeding could not be identified.

Three medical experts agreed that to leave a loop of bowel trapped in this way would be a gross surgical error. This brought into question whether or not the ileostomy was working post-operatively. Evidence in the clinical records supported the fact that it was and, at trial, the judge concluded that the bowel could not have been trapped until and including the third post-operative day and, if at all, this would have been at the end of the second operation.

The claimant also claimed that there had been a breach of the terms of the contract with the surgeon, who treated the patient on a private basis. However, the judge considered that these allegations added nothing to the duty owed in tort. The judge said she did not doubt that the claimant gave an account of events which precisely reflected her memory of them but her recollections were at odds with those of the clinical and nursing staff and with the contemporaneous records. The claimant failed to provide sufficient evidence to support her allegations and the claim was dismissed.

Lynne McNamara
Senior claims handler

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