Abstract
Damages agreed at £810,000 (July 2013)
The claimant was aged 76 years at settlement.
Heads of loss were not separately broken down but, for the purposes of settlement, the claimant’s split was as follows for the main heads:
PSLA £88,000
Past care and expenses £88,000
Future care £300,000
Future aids/transport £64,000
Accommodation £243,000
Summary of claim
The claimant underwent left total knee replacement surgery for osteoarthritis in November 2007. He had a number of pre-existing health problems, including type II diabetes, psoriasis and diverticulitis. He had previously undergone a successful replacement of his right knee.
Surgery proceeded without complication, but within three to four days the wound began to bleed, opened up, and on 13 December 2007,he attended A&E. The wound was red and painful. A swab was taken and he was given Flucloxacillin. No instruction was given for him to telephone for results. The lab reported Group B Streptococcus that was sensitive to flucloxacillin but at very high doses and recommended changing to amoxicillin. He was not informed of the result, and no change was made to the antibiotics.
His condition continued to deteriorate and on 22 December 2007, he was admitted as an emergency. He underwent open debridement, wash out and liner exchange on 22 December 2007, and it was confirmed the infection was ‘as before’ and also present in his blood stream, so he had Group B streptococcal septicaemia.
The standards of hygiene in the hospital were very poor, with dirty dressings on windowsills, clean sheets put on top of soiled sheets, and empty hand-sanitizer bottles.
Following discharge and review, it was decided the implant needed to come out, and he underwent first-stage revision surgery on 1 February 2008. Tissue samples grew coagulase negative staphylococcus, but no Group B strep. He was given IV vancomycin for two weeks and oral linezolid for three weeks.
The claimant was discharged in a leg splint and was significantly disabled in his home, which is a Victorian terraced house built on four levels with an upstairs bathroom. He was effectively confined to two rooms downstairs.
He underwent second stage of revision surgery on 23 May 2008 and was prescribed prophylactic Cefuroxime peri-operatively, but no intra-operative samples were taken for microscopy and culture. A wound swab taken on 27 May 2008 grew coagulase negative staphylococcus, the same organism found at the time of the first-stage revision surgery, but no further intravenous antibiotics were prescribed.
The claimant was discharged on 26 May 2008 with the wound still oozing; it continued to discharge and he was re-admitted on 29 May 2008. A wound swab confirmed coagulase negative staphylococcus once again, but still no antibiotics were prescribed. His C-reactive protein (CRP) was recorded to be 22 µg/ml. On 5 June 2007, his CRP was recorded as 152 µg/ml, the wound was oozing and painful but he was discharged.
Over the days following his discharge, the wound deteriorated so that the prosthesis became visible through the wound. The claimant was in a very distressed state and in great pain, and on 10 June 2008, his GP requested his readmission.
On 11 June 2008, he underwent surgery for debridement and washout. It was noted at surgery that he had a post-op open wound of the left knee with the patella and prosthesis seen.
On 13 June 2008, he underwent surgery for further debridement under general anaesthetic, and the following day was transferred to another hospital for plastic surgery review.
The options of arthrodesis and amputation were discussed, and the consultant orthopaedic surgeon advised that arthrodesis may well result in amputation in any event. Accordingly, the claimant underwent surgery for above knee amputation of his left leg on 19 June 2008.
The allegations of negligence included:
Failure to recognise that the claimant had suffered a significant complication of the replacement surgery and to manage this complication appropriately. They simply closed the wound in A&E and discharged him with empiric antibiotic treatment, rather than admitting him to for intravenous antibiotics, formal wound assessment, preferably under general anaesthetic with exploration of the wound, debridement and formal washout. Multiple samples should have been taken for culture and sensitivity testing, and inflammatory markers should have been assessed; With admission on 13 December 2007 and appropriate treatment, the claimant’s wound infection would have been successfully treated and he would not have suffered infection of the knee prosthesis and would have avoided all subsequent injury and procedures; Failure to take action on the results of the wound swab taken on 13 December 2007, by recalling the claimant so that he could be admitted, for IV antibiotics, formal wound assessment with exploration of the wound, debridement and formal washout, which would successfully have treated the infection. Following the first-stage revision, operative sampling had revealed a coagulase negative staphylococcal prosthetic joint infection. The hospital’s reliance on a drug, linezolid, which is only bacteriostatic (not bactericidal) against staphylococci, was unreasonable in the management of this staphylococcal infection, and he should have received at least six weeks treatment with intravenous vancomycin between the first- and second-stage revision surgery, which would have treated the infection. They failed to take samples for microscopy and culture during the second-stage revision procedure to confirm whether the infection had been eradicated and the identity and sensitivity of any infecting organisms; the prescription of prophylactic Cefuroxime peri-operatively was unreasonable as it took no account of the infecting organism at previous surgery. Coagulase negative staphylococcus is usually resistant to cefuroxime and IV vancomycin should have been prescribed; Despite the wound swab taken on 27 May 2008 growing coagulase negative staphylococcus, no further IV antibiotics were prescribed. IV vancomycin should have been prescribed; the claimant’s discharge on 29 May 2008 was unreasonable, when he had an oozing wound following revision surgery for overwhelming infection. He should have been kept in hospital, until the wound had settled and he had been properly evaluated for the risk of infection; The claimant’s discharge on 5 June 2008 was unreasonable given he still had an oozing wound and a CRP of 152. He required re-debridement, close wound monitoring, serial CRP measurements and intravenous vancomycin treatment over several weeks or months; With appropriate management following the operation of 23 May 2008, the claimant would have avoided amputation. He would probably then have undergone fusion of the left knee and would have been left with substantially greater function and independence than he now has; Further, it was alleged that the poor standards of hygiene in the hospital caused or materially contributed to the introduction of the claimant’s infection.
The claimant’s amputation was at a high site and this, together with his psoriasis, made the fitting of a prosthesis very difficult, and he is now wheelchair bound but can transfer and is likely to be able to continue to do so. He suffers phantom limb pains, which are likely to continue.
It was agreed his present accommodation is unsuitable, but the cost of alternative accommodation was disputed, as was the cost of future care. A multiplier of 9.5 was agreed.