MR RICHARD MILNER M.D., L.L.M., F.R.C.S.
Consultant Plastic, Reconstructive & Hand Surgeon
TO THE COURT
REPORT UPON
Josephine Bloggs – dob: 19/10/83
42 Main Street Oldtown Co Durham DH6 5TN
Date of medical report: 5 November 2013
MR RICHARD MILNER M.D., L.L.M., F.R.C.S.
Consultant Plastic, Reconstructive & Hand Surgeon
REPORT BASED ON NHS LA
CLINICAL NEGLIGENCE REPORT GUIDELINES
UPON
Josephine Bloggs – dob: 19/10/83
42 Main Street Oldtown Co Durham DH6 5TN
DATE OF INCIDENT: 12 August 2010.
SUBSTANCE OF INSTRUCTION:
To review enclosed papers and provide a report in relation to allegations of breach of duty and causation. I have not undertaken an examination of the claimant.
INSTRUCTING PARTY:
Dryburn LLP
Market Place
Middle Street
Bedale
YO99 7UD
THE WRITER:
I am a Consultant Plastic, Reconstructive & Hand Surgeon at the Newcastle upon Tyne Hospitals NHS Foundation Trust working at the Royal Victoria Infirmary, Newcastle upon Tyne. I was appointed to this post in 1992.
DOCUMENTS SEEN:
1)Pre-action protocol letter dated 17 July 2013.
2)Letter of Claim.
3)University Hospitals Bedale NHS Foundation Trust medical records.
4)North Bedale NHS Trust medical records.
5)Radiographs in CD format.
1)SYNOPSIS AND CHRONOLOGY:
1.1)Background:
The claim concerns the alleged negligent treatment provided to the Claimant on 12 and 23 August 2010.
1.2)On 12 August 2010 the Claimant cut both her hands on a window which broke as she was closing it. She attended the accident and emergency department at the Bedale Royal Infirmary where it was noted that she had a crush injury and a laceration to her left hand and arrangements were made for review in Middleton Infirmary the following day.
1.3)It is alleged that had the Claimant been examined properly in the accident and emergency department on 12 August 2010 the extent of her injuries would have been identified and surgery would have been planned accordingly.
1.4)It is further alleged that as a result of the alleged negligence the Claimant required further and unavoidable complex surgery as a result of the failure to treat the thumb tendon injury and to correctly identify the anatomy in respect of tendon repairs and that she has more extensive scarring to the back of her hand and an avoidable scar on her forearm and that she is experiencing significant pain and suffering.
1.5)When she attended the accident and emergency department at Bedale Royal Infirmary. It is noted that the glass in the window had shattered and she had sustained a laceration to the dorsum of her right hand and a smaller one to her left hand. There are two illustrations, each of the dorsum of the left and right hands with a laceration on the left hand at the base of the middle, ring and index fingers and on her right dominant hand an irregular laceration over the mid dorsum. It was noted there was a right index finger extension deficit. The wounds were closed under local anaesthetic. An x-ray was reported as showing no obvious fracture. The hands were dressed and arrangements were made for review at Middleton Infirmary the following day.
1.6)On 13 August 2010 she was reviewed in the plastic surgery trauma assessment unit and it was noted that she had sustained lacerations to both hands the previous evening, the right was more affected than the left. The left hand was noted to have mild bruising and swelling and NBI (no bony injury). The right hand had a laceration over the central aspect of the dorsum of the hand. An x-ray was reported as showing no abnormality. The extensor tendon to the right index finger was thought to be divided in zone 6(The extensors on the dorsum of the hand, wrist, and forearm are divided into nine anatomic zones to facilitate classification and treatment of extensor tendon injuries. Zone 6 relates to the dorsum of the hand).
1.7) On 13 August 2010 she was consented for surgery, the consent was for an examination under anaesthetic of wound and extensor tendon repair right hand.
1.8)On 14 August 2010 she underwent an operation under general anaesthetic,
“Repair of Right Extensor Indicis and Extensor Digitorum to Right Index.
Tourniquet applied/tourniquet time 47 minutes.
Incision: Debridement of skin edges and incision as shown. (There is a diagram of the dorsum of the hand showing a transverse laceration and a curved proximal incision with the skin being rotated for ease of closure.)
Findings: 100% division of extensor indicis and extensor digitorum to right index finger/intact extensor to middle finger.
Hand is markedly swollen.
Large haematoma proximal to laceration.
Ragged laceration with skin loss.
Ragged laceration (superficial) to 1st and 2nd dorsal interossei.
Procedure: Evacuation of haematoma.
Washout+++ (500ml of saline and H2O2 and 500mls of saline)
Repair of the EI and ED (abbreviations for “extensor indicis” and “extensor digitorum” with 3-0 Prolene (modified Kesslers) and Silverskfold with 6-0 PDS.
Incision for exploration used to lift transposition flap to cover skin detect (hand is markedly swollen).
Tourniquet down – haemostasis.
Closure 5-0 Prolene to skin.”
The patient was discharged later that day.
1.9)On 18 August 2010 she attended her first physiotherapy session at Frenchay Hand Centre and the right hand was noted to be grossly swollen. She was reviewed on 4-6 further occasions and on the latter occasion on 23 September 2010 which was six weeks post-operatively she was still concerned she had not regained a full range of movement and there was noted to be tethering.
1.10)It was noted she was unable to extend her thumb interphalangeal joint and referral to a hand surgeon as made.
1.11)She was reviewed by the physiotherapist in the hand centre and the range of motion was noted for the metacarpophalangeal joint of the right ring finger to be 0/55o and the middle finger 0/50o and that she was worried about the level of function.
1.12)On 3 October 2010 she was admitted to Middleton Infirmary.
1.13)3 October 2010 operation under general anaesthetic undertaken by MrS Bunnell,
“Operation: Re-exploration Right Hand and Repair ECRB, EPL (Palmaris Longus Tendon Graft) and EI.
Findings: ED/EI found unrepaired proximally under extensor retinaculum.
ECRB repaired to EDC/EI.
EPL – 100% divided, found unrepaired.
Procedure:
1)ECRB – anchored to metacarpal.
2)Fascial sling over top.
3)EPL too short therefore repaired with right palmaris longus graft. 3 x weave (Pulvertaft weave) at each end clear of tunnel. 3-0 Prolene to hold under fascial sling.
4)EI – EDC (as EI too short).
- double Kessler 3-0 Prolene/6-0 Prolene.
5)EDC distally to EDC middle finger. (3.0 Prolene).
Haemostasis.
5.0 Ethilon closure.”
There is an illustration of the dorsum of the hand showing an extension proximally of the curved scar over the mid dorsum of the right hand.
1.14)She was reviewed in the hand centre on 5, 8, 11 and 15 October and on the latter occasion the following was noted,
“… Worried as having “nerve pain” in early hours of morning – waking. Concerned re how flap looking.” …
She continued with physiotherapy and on 1 November 2010 the following was noted,
“Small slough open area.
Redressed.”
She was noted to have no lag in extension with her fingers abducted but with the fingers adducted there was 20o of lag. Good EPL function but a lag of 10o. Splintage was continued.
1.15)She underwent 12 more visits to the hand centre up to 20 December 2010 when the following was noted,
“Index finger feeling stiff and painful – has struggled …
IFMF
Active range of movement:0-55o0-76o
Passive range of movement:0-70o with hold at 62o
Wrist (A) flexion 40o
(P) flexion 50o
Thumb (A) Kapandji 8/10
(P) Kapandji 10/10.”
(Kapandji is a clinical test for opposition of the thumb; this records where the tip of the thumb touches the index, middle, ring and finally the little fingers. Each position being awarded a numerical score; 8 is where the thumb touches the proximal interphalangeal joint of the little finger and 10 when it reaches the distal palmar crease of the hand.)
1.16)She was reviewed by Mr Verdan, consultant plastic surgeon, in the plastic surgery out patient clinic. He noted that she was,
“Tight in the extensor mechanism of the index finger, however, she is making steady, if somewhat slow progress. She should continue with her hand therapy at present. … I have warned her that at some stage she may need a tenolysis procedure if the tendon does not free up some more. … On the plus side all the tendon repairs are intact at this present moment in time so I think things are positive there. …”
1.17)She was seen in the hand clinic on 1 February 2011 and the following noted,
“Still difficulty with fine dexterity.
Pain dorsum of hand on lifting pans, etc. Still very stiff.
Active range of movement index finger metacarpophalangeal joint 0/76.”
1.18)She was seen in the hand clinic on 7 March 2011 and the following noted,
“Getting tight sensation on dorsum of hand over dense part of scar. Scar much flatter and more mobile.
MCPJ1 0/72o index finger.”
1.19)She was reviewed by Mr Verdan on 3 May 2011 and the following noted,
“Doing functionally well.
0/45 at MCPJ index.”
1.20)She was seen in the hand clinic on 18 November 2011 and the following noted,
“Hand function improved since last review. Still clumsy.
Thumb extensor improved.
Still feels tight.”
1.21)In August 2012 Miss Bloggs accepted a post at adental practice in Canada. It is indicated she may decide on an alternative specialty to conservative dentistry.
2)BREACH OF DUTY:
2.1)I will address the areas of alleged breach of duty in the letter from Summerhill Solicitors dated 10 July 2013, reference DXM/GT53/1047425/1.
2.2)First defendant – University Bedale Healthcare NHS Trust.
1)There was a failure to conduct an appropriate examination when the Claimant attended the Accident and Emergency Department on 12 August 2010.
1a)There was a failure to note that there was an open wound as a result of glass.
Given that the claimant’s injury was sustained from glass, this should have been noted due to the possibility of foreign material contained within the wound. The failure to note the involvement of glass constituted aBreach of Duty of care.
Opinion:
It was noted that glass was involved in the injury at the triage assessment at admission and it is more likely than not that this was taken into account during the casualty officer’s assessment.
“Window slammed shut onto hand – glass shattered”.
I can see nowhere in any of the records at this examination or subsequent surgery that glass foreign bodies were present so this part of the claim appears irrelevant. Lacerations caused by glass exist in their own right whether glass foreign bodies are retained or not. I do not believe there has been a breach of duty of care here.
1b)There was a failure to examine all of the Claimant’s digits when she presented with an open wound.
Given the claimant’s injury was sustained from glass and caused an open wound examination of all of the Claimant’s digits was mandatory. Any reasonably competent practitioner would know that glass injuries can cause additional damage than immediately apparent and would have examined all the digits. The failure to perform this examination constituted a breach of duty of care.
Opinion:
The casualty officer examined both hands and made drawings of each. On the left hand at least it is recorded that all the fingers were neurovascularly intact implying that all the fingers on this hand were examined and I can see no reason to suspect why the same had not been done on the right side and with only the salient abnormality, that is, lag of extension being noted.
A decision had been made to refer this lady’s hand injuries to someone with more experience in dealing with such problems. The wound had been closed originally to protect the underlying structures and therefore the course of action had been planned. It was recognised she would require surgery and there would have been nothing further to be gained by detailed recording of each individual movement. Given that an examination would clearly have been painful and would have to been repeated at the hospital the following day in my view a detailed recording of each joint movement was unnecessary.
In my opinion there has been no breach of duty in relation to this.
2.3)Second defendant: Middleton NHS Trust.
2)There was a failure to conduct an appropriate examination on admission on 13 August 2010.
2a)There was a failure to examine the client’s individual digits on her right hand prior to surgery.
The Claimant’s medical records make no reference to any examination on the function of her individual digits ie her thumb, index, middle, ring and little fingers. Whilst there are two extensor tendons within the anatomy of the human index finger there appears to have been no attempt made to assess whether either or both of these were damaged. There was no note of any thumb function at all.
Any reasonably competent plastic surgery registrar should know that glass injuries can cause additional damage than may be immediately apparent on sight on brief examination therefore adequate examination of all extensor tendons was mandatory. The failure to conduct this examination constituted a breach of duty of care.
Opinion:
The patient was clearly going to require surgery. It would not be normal practice to remove dressings and undertake a detailed examination by the admitting junior doctor as a further examination would likely be required in any event. The risk of introduction of infection by repeated examinations in open injuries is well known.
In my opinion there has been no breach of duty in regards to this.
2.4)Second defendant: Middleton NHS Trust.
2b)There was a failure by the surgeon to examine the claimant before performing surgery on 23 August 2010. A reasonably competent surgeon would perform his own examination prior to performing surgery first to ensure that his colleagues had conducted a full examination and appreciated the full extent of the causative injury.
Opinion:
It is agreed a reasonably competent surgeon would perform his own examination to ascertain the nature of the injury though to perform a very detailed examination of finger movements is not mandatory. However the brevity of the records may suggest a very limited examination was undertaken and this is likely to have given rise to a breach of duty.
2.5)Second defendant: Middleton NHS Trust.
3)The procedure on 14 August 2010 was not carried out to an acceptable standard with reasonable care and skill.
3a)There was a failure to identify the anatomical structures during surgery and appropriately repair the tendon injuries.
The operation note on 14 August 2010 states that the findings were “ … 100% division of EI and ED to right index finger/intact extensor to the middle finger.” In full, the surgical registrar noted that he found 100% division of the extensor indicis and extensor digitorum of the right finger and intact extensor to the middle finger during the procedure. He noted that the repaired the injuries identified.
Contrastingly, the operative note from the revision procedure on 3 October 2010 states “… proximal … EI – not repaired. … EPL 100% not repaired … ECRV – EI/EDC … EDC – not repaired…” In full, the extensor carpi radialis brevis had been sutured to the extensor indicis and extensor digitorum communis, and the extensor digitorum communis had not been repaired during the surgical procedure on 14 August 2010.
The failure to treat all the Claimant’s injuries and the failure to appropriately perform appropriate repairs due to the failure to correctly identify the anatomy, constituted a breach of duty of care.
Opinion:
Given the subsequent findings at the operation of 3 October where several divided tendons appear to have remained unidentified it would be difficult to maintain that the surgical procedure undertaken on 14 August 2010 did not fall below a reasonable standard of care.
3)CAUSATION:
3.1)First Defendant – University Bedale Healthcare NHS Trust.
1)But for the substandard examination within the Accident and Emergency Department the Plastic Surgery Department would have been aware of the true extent of the Claimant’s injuries and planned surgery accordingly ie her thumb injury would have been detected and treated.
Opinion:
The casualty officer’s duty is to make a sound enough assessment to ensure the patient receives appropriate definitive treatment at that stage or to have sufficient treatment prior to beingtransferred on to a more experienced treating doctor. The assumption was that the subsequent care that the patient received would have been adequate. I believe that there was no breach of duty regarding the patients assessment at Bedale Royal Infirmary and consequently I cannot see that the chain of causation here is intact.
2)The Claimant required further and avoidable complex surgery in the form a tendon graft, which was performed on 3 October 2010.
Opinion:
In the absence of a breach of duty I do not think that this causal link can be made.
3)The Claimant has more extensive scarring to the back of her hand and an avoidable scar to her forearm.
Opinion:
In the absence of a breach of duty I do not believe that achain of causation exists.
3.2)Second Defendant – Middleton NHS Trust.
1)The Claimant required further and avoidable complex surgery, which was performed on 3 October 2010 as a result of the failure to treat the thumb tendon injury and to correctly identify the anatomy in respect of tendon repairs conducted.
Opinion:
I believe this is correct.
2)As a result of the substandard procedure on 3 October 2010, the Claimant has more extensive scarring to the back of her hand and an avoidable scar to her forearm.
Opinion:
It is not my belief that the surgery undertaken on 3 October 2010 was undertaken to a substandard level. In fact, the opposite, I think the surgery was appropriate and whilst complicated it rescued a difficult situation. This aspect of causation in regards to the second defendant relates to the procedure on 3 October 2010 as a result of which the Claimant has more extensive scarring on the back of her hand