Abstract
Background
In May 2004, DP, aged 34 (born 8th March 1970) was a police officer who was undertaking firearms training when he injured his right Achilles tendon. He underwent surgical repair at Luton and Dunstable Hospital in July 2004. A post-operative infection was treated with antibiotics and appeared to resolve. He continued to suffer pain, was referred to a pain clinic and treated with Amitriptyline and Gabapentin.
An MRI scan showed a thickening of the tendon and a cyst, and in August 2005 he underwent a Bosworth repair. He was reviewed by his orthopaedic surgeon in September 2005 and then on 6th October 2005, when the plaster was removed. After inspecting the wound, the surgeon asked a nurse to clean it. He then left the consultation room. On the Claimant's account, the nurse pointed out that a stitch was protruding from the wound, said that it was a dissolvable suture and advised him to bathe it until it dissolved.
Visitors to his home on the following three days, gave evidence that the stitch was visibly protruding from the wound. On the fourth day, he attended the Police Rehabilitation Centre where a physiotherapist noted the stitch and thought the wound was infected. She arranged for a GP to visit. The GP cleaned the wound, removed some suture material (which the Claimant retained) and prescribed antibiotics. In late October 2005, he saw the orthopaedic surgeon who diagnosed a stitch abscess and prescribed antibiotics.
Management of the infection proved difficult and in January 2006 DP was referred to a plastic surgeon. The plastic surgeon referred him for surgical exploration and creation of a v-y flap, which was not done until March 2006. The findings at surgery were of no continuing infection. However, his post-operative recovery was again delayed by infection.
Unfortunately, DP remained in considerable pain. He underwent a further tendon repair in September 2006 and an ankle fusion in May 2007. He was referred again to a pain clinic and diagnosed as suffering from Chronic Regional Pain Syndrome (CRPS). On 3rd March 2008, he underwent a below-knee amputation.
On 2nd March 2008, he was medically retired from the police.
A claim was brought against the Luton and Dunstable Hospital NHS Foundation Trust for negligent mismanagement of the stitch on 6th October 2006 his infection.
Issues
There was a dispute of fact as to the events of 6th October 2006. The Claimant alleged that the stitch had been protruding and that he had been advised to soak it in the bath. The Defendants denied this and there was, unsurprisingly, no record corroborating the Claimant's account in the medical records.
He alleged that correct management on 6th October 2006 would have been either to remove the stitch in sterile environment or cover it with a sterile dressing until it could have been removed. Leaving the stitch in place and particularly soaking it in the bath, created a conduit for infection to the tendon itself. There were further alleged breaches of duty in failing to admit the Claimant urgently for more aggressive management of the infection, including intravenous antibiotics and surgical debridement, which the Defendants denied.
On causation, the principal issues were whether the infection predated the appointment of 6th October 2006, what was the cause of the stitch protruding and whether more aggressive management would have made any difference to the outcome.
Claimant's Case
The Claimant alleged that the nurse, on 6th October 2006, negligently failed to draw the clinician's attention to the protruding stitch, advised him to soak it in the bath and discharged him from the clinic with a piece of deep suture material protruding. The issue here was primarily one of fact, but nursing evidence supported the claim that these allegations, if proved, would amount to breaches of duty.
On the basis of orthopaedic evidence, he alleged that had the nurse referred the Claimant back to his clinician, the stitch would probably have been removed in a sterile environment that day, but if facilities were not immediately available, the wound would have been covered to keep it sterile and the stitch be removed the next day. Once exposed and particularly when soaked in the bath, the stitch became a conduit for infection to the deep tissues. Blood supply to the tendon would have been limited and once the tendon itself was infected, the infection would prove difficult to manage. However, aggressive management before late November 2006 to include intravenous antibiotics and surgical debridement (with assistance from a microbiologist) would, on the balance of probabilities, have eradicated the infection before it caused irreparable damage to the tendon.
The orthopaedic surgeon's evidence was supported by that of a microbiologist, who agreed that, in the absence of signs of infection between surgery in August 2006 and the plaster being removed in October 2006, the infection post-dated the appointment of 6th October 2006 and that the protruding suture was therefore the conduit. She also agreed that aggressive management by late November 2006 would have eradicated the infection.
A Plastic Surgeon was also critical of delays in carrying out debridement between January and March 2006 and then of the post-operative antiobiotic regime. However, the dye was in his view cast by that stage.
A Pain Management Consultant concluded that the Claimant was had suffered previous sensitivity to pain and was vulnerable to CRPS but did not develop full CRPS until after January 2006. CRPS proved extremely difficult to manage and led ultimately to amputation.
Defendants' Case
The Defendants denied that any suture material was protruding from the wound on 6th October 2006 and supported their defence with a very thorough witness statement from the nurse concerned. Although she could not recall the incident, she was very experienced and said that she would not have mistaken a non-dissolvable suture for a skin suture or given the advice to soak it in the bath.
On causation, they alleged that infection must have predated 6th October 2006 (probably originating at the time of surgery) and was the cause of the stitch protruding. In the absence of such an infection there would be no reason for it to break through the skin. In the alternative, they said that if the stitch had acted as a portal for infection, soaking it in the bath would not have made a difference.
Proceedings
Proceedings were issued in the High Court and defended. Witness statements were exchanged.
Quantum
The Claimant valued the claim as follows:
£60,000 £108,000 £30,000 £240,000 £50,000 £200,000 £130,000 £250,000 £160,000 £1,228,000
Settlement
Before exchange of expert evidence, the Defendants accepted a Claimant's Part 36 offer to pay damages of £850,000. The settlement represented 70% of the Claimant's valuation of the claim, discounted to reflect the risks on both breach of duty and causation.