Mrs T, a 45-year-old solicitor, was diagnosed with an 8cm complex left ovarian mass following some months of left iliac fossa pain. Mrs T had had two previous laparotomies, one for a right oophorectomy and latterly a hysterectomy. The right oophorectomy had been for a dermoid cyst and the hysterectomy for menorrhagia. Mrs T attended the clinic where she saw Ms D, gynaecology consultant, who advised her to have surgery to remove the ovarian mass.
The surgery was complicated due to the presence of considerable adhesions involving the ovarian mass, large bowel and pelvic side-wall. The left ureter was identified and mobilised clear of the left ovarian mass, which was excised as planned. Some hours after the surgery, Ms D had a family emergency and she had to leave the country for a few days. She asked her colleague Mr G to keep an eye on her patients while she was away.
The first 72 hours after surgery were uneventful, although Mrs T was making slow progress. She was drinking but did not have much of an appetite. She felt bloated and had not passed much flatus nor had she opened her bowels. Indeed, Mrs T’s abdomen was distended and her abdominal wound was beginning to discharge offensive material. The nurses tried unsuccessfully to contact Ms D. Mr G reviewed Mrs T a few times and also checked Ms D’s surgical notes.
The documentation was scarce and there was no mention of adhesions or any difficulty encountered during surgery. Mr G decided to adopt a conservative approach as Mrs T’s general condition remained stable, even though the wound continued to discharge. He mentioned to other colleagues that he felt it was difficult to interfere with the care of a senior colleague’s patient as he felt intimidated by Ms D. As a precaution, Mrs T was prescribed broad-spectrum antibiotics.
A week after the initial surgery, Mrs T’s condition deteriorated and she developed an acute abdomen. She had generalised abdominal pain and vomiting, along with a fever and a raised white cell count. Mr G took her to theatre for an emergency laparotomy to find faecal peritonitis and a loculated pelvic collection. There were several perforations of the sigmoid colon which necessitated partial bowel resection and a colostomy. Further surgery was required before Mrs T was finally discharged home two months later.
The case was settled for a moderate sum. Allegations of negligence were in relation to bowel perforation, delay in diagnosis and poor postoperative care.
LEARNING POINTS
An operative note is for the benefit of all personnel looking after a patient. The record should not only give an account of the operation performed, but it should also accurately reflect any degree of difficulty of the procedure or deviation from the norm. Ms D failed to do this.
Good surgical documentation can alert colleagues to an ensuing postoperative complication and may facilitate early intervention and treatment.
It is important to ensure appropriate arrangements are in place when leaving patients in someone else’s care. Ms D did in fact do this by informing her colleague Mr G, but it seems she did not inform the ward nursing staff. It is good practice to advise the nursing staff which doctor will be responsible for your patients in your absence. Not only did Ms D fail to write comprehensive surgical notes, but she also should have conveyed the intraoperative difficulties she had to Mr G.
If you are covering for a colleague, you must take full responsibility for those patients. A patient’s care should not be compromised for fear of offending a colleague. Mr G’s remark that he found it difficult to interfere with a colleague’s patient is difficult to accept, given that Ms D had asked Mr G to look after her patients. If there is uncertainty over how a patient should be managed, you should consider asking the opinion of a colleague.
A wound that is discharging offensive material following intraperitoneal surgery should be investigated promptly. You need to consider the possibility of bowel injury. In this case, the use of radiological imaging may have helped confirm a significant complication and facilitated earlier intervention.
Adapted from a case report which was published on 10 January 2012.