Abstract
M (GP with Hodgkin's disease) admitted to hospital with high fever and right-sided abdominal pain. Possible mass in right iliac fossa identified on day of admission by specialist registrar. Ultrasound scan performed two days later showing thick-walled loop of bowel in right flank corresponding to area of discomfort indicated by M. Investigation focused on echocardiography and possible tropical and other infective diseases rather than acute inflammatory bowel pathology. CT scan obtained eight days after admission demonstrated extension of inflammatory changes into surrounding mesenteric fat and development of liver abscess. Eleven days after admission, surgical opinion obtained for first time. Surgeon performed urgent operation. Perforation of caecum confirmed. Terminal ileum and right colon resected. Primary anastomosis rather than ileostomy. M's condition deteriorated. Second laparatomy performed seven days later. M remained septicaemic with deterioration into full-blown adult respiratory distress syndrome and multiorgan failure culminating in death on 1 February 2002.
Background to Claim
M was a general practitioner. At the age of 49, in June 2001, he was diagnosed with nodular sclerosing Hodgkin's disease. His disease was classified as stage IIIB disease and he was treated with ABVD chemotherapy, which he tolerated well. His last chemotherapy session was on 4 January 2002.
On 7 January 2002, M was admitted to St James' Hospital, Leeds, with a high temperature and right-sided abdominal pain. He was examined by a specialist registrar who noted an ‘impression of mass’ in M's right iliac fossa and recommended that an ultrasound scan be obtained.
The ultrasound scan was carried out two days later and the report included the following: ‘there is a thick-walled loop of bowel in the right flank, which corresponds to the area of discomfort indicated by the patient. This could be due to an inflammatory process, but lymphomatous infiltration is also possible.’ Medical opinion excluded the latter suggestion on the grounds that Hodgkin's disease (in contrast to non-Hodgkin's lymphoma) does not infiltrate bowel.
Between 9 and 15 January 2002, with some record of brief but temporary improvement, M remained unwell with spiking temperatures accompanied by rigors, pain and discomfort. He was seen by a specialist registrar in infectious diseases on 11 January. M and his wife were careful travellers who took appropriate prophylaxis if travelling to malarial zones and M had tested negative for malaria before his Hodgkin's disease was diagnosed.
On the same date (11 January 2002), M was seen by a consultant medical oncologist who advised an ‘early’ CT scan. He was treated with intravenous cerufoxime. While it was reasonable to consider TB as a differential diagnosis, the focus of those treating M was a systemic source of infection when clinical examination would have shown and did show a likely localized source of infection in the right iliac fossa. No consideration was given to the possibility that M's condition might be related to previous chemotherapy.
There was no record over this period of clinical examination of the abdomen until 14 January 2002 when a note was made of ‘a suggestion of mass and definite fullness’. M developed increasingly severe pain in the right iliac fossa associated with rigors. He received morphine for pain relief.
N stated that M repeatedly told the doctors that he thought there might be bowel obstruction. He was acutely aware of his deteriorating condition and, in due course, of the fact that he was going to die. He asked his wife to move him from the hospital. She encouraged him to believe that he was in an excellent hospital and should trust those treating him.
On 15 January, a CT scan was performed which showed ‘a 5 × 5 cm low attenuation lesion in the left lobe of the liver’ and ‘gross thickening and enhancement of the caecum and distal ileum with inflammatory changes noted in the surrounding fat’. Still no surgical opinion was sought.
The findings on the scan were not investigated further until 18 January 2002. On that date, after plain abdominal X-ray revealed considerable extension of small intestine and there was a further increase in leucocytosis together with sharp falls in haemoglobin and serum albumin, M was seen for the first time by a consultant surgeon who diagnosed a ‘source of abdominal sepsis’. The following day, the surgeon performed a laparatomy, which disclosed caecal perforation and liver abscess. He carried out a right hemicolectomy and ileocolic end-to-end anastomosis.
M remained very ill. He underwent a second laparotomy on 25 January 2002 and died on 1 February 2002 as a result of sepsis and multiple organ failure consequent upon the perforation of his caecum due to necrotizing colitis (possibly neutropenic colitis).
N brought a claim against the Trust on behalf of M's estate and his dependants, including their two teenage sons. The claim was settled in 2006.
Liability
Negligence was alleged both against the medical members of the oncology team and against the surgeon who, on 19 January 2002, carried out a primary anastomosis, rather than a terminal ileostomy and colonic mucous fistula.
The allegations against the medical members of the oncology team focused on the failure to investigate the possible mass in the right iliac fossa as a matter of urgency once it had been identified and the failure to appreciate by 9 January 2002 at the latest that the likely cause of M's illness was a source of infection in his right flank. Further allegations were made as to the failure to obtain a surgical opinion once the ultrasound scan had identified a thick-walled loop of bowel in the right flank and the failure to carry out sufficient clinical examinations. An allegation was made that a differential diagnosis of neutropenic enterocolitis should have been made in view of M's treatment by chemotherapy.
The Trust admitted negligence in relation to M's treatment, on a limited basis. It admitted that a surgical opinion into M's condition should have been sought on 15 January 2002 and that, if such an opinion had been sought, an operation would have taken place by no earlier than 17 January 2002. M's chances of survival following surgery on that date would have been in excess of 80%. For that reason, the Trust was prepared to meet M's claim in full and his further allegations of negligence could not reasonably be pursued.
The case was settled for a substantial sum, which took into account only a very small reduction in life expectancy. Evidence as to M's life expectancy but for the Trust's negligence had been obtained from Dr Hilmar Warenius, Professor of Oncology Research at Liverpool University.
Further allegations of negligence
The further allegations of negligence, while not admitted, raised an interesting question as to the connection between chemotherapy and the infection.
A medical report was obtained on the Claimant's behalf from Mr GD Oates, Consultant in Surgical Oncology, Colorectal Surgery and General Surgery. His view was that the differential diagnosis in this case should have focused on an inflammatory aetiology. If this had been done, top of the list should have been the condition of neutropenic enterocolitis, which is a condition known to be a potential risk in patients receiving polychemotherapy for lymphoma and other haematological malignancies. There was a potentially contentious issue as to whether there was a known causative link between ABVD chemotherapy and neutropenia and, if so, whether this was something of which the members of the Medical Oncology team should have been aware.
In relation to the surgery on 19 January 2002, the case against the surgeon appeared strong. During the preoperative interview with M and his family, the surgeon had said that the finding of a perforated caecum would represent the need for a temporary stoma and yet he carried out a primary anastomosis. Mr Oates felt certain that the entire body of colorectal and general surgeons would consider a primary anastomosis to be contraindicated in the circumstances.
Conclusion
This case raised serious issues of diagnosis, and interdisciplinary and doctor–patient communication. At the centre of the case lay a failure to appreciate the significance of the mass in the right iliac fossa as a source of infection and the possible significance of M's treatment by chemotherapy. Mr Oates' strong view was that a surgical opinion should have been sought at an early stage. If surgical opinion had been sought, the likely local source of infection would have been recognized and there would have been aggressive intravenous antibiotic treatment followed, if necessary, by early surgical intervention. In either event, the prognosis was good and M's prospects of survival were significantly higher than 50%.
The family considered that M's own opinion as to his condition appeared not to be listened to by those treating him. He was an experienced medical practitioner who had given more than 20 years' loyal service to the NHS. While these facts gave rise to no specific allegation of negligence, they exacerbated considerably the family's feelings of distress at his premature and negligently-caused death.