Cases: Delay in surgical re-intervention leading to death

Background

Arthur Hough, the deceased, was born on 4 September 1945.

From March 2004, when the deceased was 58 years old, he began to complain of pain in his epigastrium and upper central abdomen. From April to June 2004, he underwent investigation including an ultrasound scan of his abdomen and liver and a pancreatic computerized tomography (CT) scan.

A colonoscopy and gastro-duodonoscopy performed on 15 July 2004 concluded that the deceased was then in subacute intestinal obstruction from an intussuscepting cancer at the splenic flexure and required emergency surgery.

The deceased underwent an emergency laparotomy on 15 July 2004 when an obstructing carcinoma was found at the splenic flexure. There were no palpable nodes. A proximal large bowel and small bowel were grossly dilated. The liver was clear. The splenic flexure tumour was resected. After the initial resection, the proximal bowel was dusty from ischaemia and a further bowel resection was necessary. A double-barrel colostomy and mucus fistula were performed.

Histology of the resected bowel revealed a moderately well-differentiated invasive adenocarcinoma of the colon which was infiltrating through the muscularis propria into the mesenteric fat. A diagnosis of invasive adenocarcinoma Dukes B was made.

Mr Hough had a stormy postoperative course. He was tachycardic and had poor urine output. His blood pressure was low and respiratory rate high. By 07:45 on 17 July 2004, the second postoperative day, he had a metabolic acidosis and was diagnosed with septic shock. At 13:35 he was diagnosed with left-sided pneumonia.

By 16:55 he had a worsening acidosis. His pH was 7.17 with a base excess of –18.3. He required increasing Noradrenaline to maintain blood pressure. He was acidotic with significant fluid losses from the gastrointestinal tract. His stoma appeared necrotic. He continued to deteriorate further during the remainder of that day.

On the morning of 18 July, he was oliguric, pyrexial and his blood pressure was maintained on Noradrenaline and Dopexamine. He had fast atrial fibrillation. He continued to be acidotic and the exposed part of his stoma was gangrenous. At 09:00, a decision was taken to proceed with a re-laparotomy for peritonitis.

Surgery was commenced at 11:30. Mr Hough had advanced faecal peritonitis with a leak of faecal contents from the stoma site into the peritoneal cavity. The area where the proximal and distal stoma was joined had retracted into the peritoneal cavity and was leaking faeces into the abdomen. Histology of the further bowel resected revealed colostomy necrosis due to ischaemia.

Despite ongoing medical care, the deceased continued to suffer from ongoing sepsis and its complications. He developed multiple organ failure; his abdomen continued to drain faecal fluid. He had multiple bowel fistulae. He remained septic with a swinging pyrexia. He required a tracheostomy.

At the end of August 2004, he developed an abdominal wound dehiscence with an open abdominal wound with muscle weakness. He required TPN feeding and had deranged liver function test results.

By November 2004, he had developed an MRSA infection.

In early November his condition deteriorated, he had a distended abdomen and the colostomy was not working. The deceased developed renal failure and began to deteriorate further. His septicaemia worsened and he died on 18 November 2004. The cause of death was recorded as hepato-renal failure due to septicaemia due to peritonitis.

The Claimant's case

A claim was advanced by Lynn Hough, the deceased's widow as the deceased's dependant, under the Fatal Accidents Act 1976 and on behalf of her husband's estate under The Law Reform (Miscellaneous Provisions) Act 1934.

No criticisms were made of the management of the obstructing splenic flexure carcinoma and the operation on 15 July 2004. It was alleged that there was a delay in intervening for faecal peritonitis. The clinical picture on 17 July 2004 should have been managed by re-laparotomy. Had a re-laparotomy been performed at any stage during 17 July, the consequence arising from the faecal peritonitis would have been far less. Respiratory failure, intra-abdominal sepsis, faecal fistula, tracheostomy, renal failure and subsequent hepatic failure with immune suppression would not have occurred and the deceased would have survived.

The deceased was 59 years old when he was diagnosed with carcinoma of the colon. On the balance of probabilities, had he been appropriately treated, he had a favourable outcome from his tumour and his life expectancy would not have been affected by the tumour.

Breach of duty in part was admitted in the pre-action period, the Trust's position on causation being reserved.

Following the service of proceedings, no defence was offered by the Trust and Judgment was entered for the Claimant for damages to be assessed. A letter of apology was provided to the Claimant.

Settlement

Following Judgment being entered, a stay was agreed to allow settlement discussions to take place. These stalled when the Trust sought to argue that the pension receipts the Claimant received following her husband's death, had to be brought into account in calculating the dependency claim. This assertion was clearly wrong by virtue of s4 of the Fatal Accidents Act 1976. When this assertion was withdrawn, the case settled for £295,000 broken down as follows: