The Penningtons Manches clinical negligence team has recently agreed the settlement of a claim against St Helier Hospital, Surrey, for an alleged failure to appropriately diagnose appendicitis at an early stage, causing a delay in much needed surgery.
The firm’s client initially attended St Helier Hospital on 9 December 2013 with very severe abdominal pain and vomiting. An examination was performed by an A&E clinician, and she was prescribed antiemetics and Buscopan. As the pain was noted to have ‘settled’ after taking this medication, she was discharged home with a diagnosis of gastroenteritis.
However, the patient’s condition deteriorated, and consequently, she returned to A&E during the late night of 11 December 2013 via ambulance, with a complaint of severe abdominal pain which was noted to be present in the ‘right abdo’ (abdomen). The paramedics documented that she was tachycardic (a fast pulse rate) and that she had a high temperature. An abdominal examination was performed, and she was noted to have tenderness in the lower right side of the abdomen. Her blood results were also abnormal, which was likely to be indicative of an inflammatory process / infection. The A&E clinicians considered appendicitis as part of a differential diagnosis and she was admitted under the care of the surgical team for further investigation into the cause of her symptoms. She was later reviewed by a consultant general surgeon who noted that the patient’s pain was persisting in her right lower abdomen. The plan was for an ultrasound scan, which was performed the following day.
The sonographer reported the findings of the scan and considered that they were consistent with either ‘a ruptured ovarian cyst or appendicitis’. A review by a surgical specialist registrar took place within a few hours of the scan when it was also noted that the results were indicative of either a ‘ruptured ovarian cyst’ or ‘appendix’. Test results available at the time showed that the patient’s abnormal blood results had continued to rise. A plan was recorded as ‘1. Eat and drink. 2. The patient to stay in and go home tonight with bloods later this week or home tomorrow with bloods tomorrow morning’. She remained in very severe pain, and was understandably very distressed at the lack of progress made in obtaining a formal diagnosis and effective treatment for her symptoms.
The following day, she was seen by her consultant surgeon, when it was noted that her condition had deteriorated and a suspicion of ‘peritonitis’ (sepsis in the abdomen) was raised. An urgent CT scan was requested, which then confirmed the diagnosis of appendicitis. She eventually underwent surgery on 15 December 2013, some six days after her initial presentation at the hospital. During the surgery, she was found to have had a ‘perforated gangrenous appendix with faecolith in RIF adherent to side wall…with purulent fluid’. Given the discovery of the ruptured appendix and sepsis, she had to undergo a very invasive operation in the form of an open laparotomy with a large midline incision. She was so unwell after her surgery that she needed to be cared for in the high dependency unit, and she had a very difficult and prolonged recovery.
The patient was concerned about the delays she experienced in the diagnosis and treatment of her appendicitis and the potential harm caused to her, so she subsequently instructed Penningtons Manches to investigate the standard of care she received. During the course of these investigations, an independent expert opinion was sought from a consultant surgeon who identified a number of failings in her care. He was of the opinion that the findings of the ultrasound scan together with the abnormal blood results should have prompted urgent further investigation, and that surgery should have been performed no later than 24 hours after the scan. He believed that if the surgeons had acted appropriately, the patient would have undergone earlier and less invasive surgery and would have had a reduced period of exposure to sepsis, which led to treatment and care in the high dependency unit. Her scarring would also not have been so significant and she would have avoided the associated distress and anxiety that arose as a result of her delayed diagnosis.
On conclusion of the expert investigations, Penningtons Manches submitted a letter of claim to the defendant trust, in accordance with the Pre-Action Protocol for the Resolution of Clinical Disputes. A full admission was subsequently received from the trust on the alleged failings in the patient’s care, although the extent to which the failings had caused her harm was disputed. After negotiating with the defendant, a reasonable settlement was secured without the need to issue court proceedings.
Naomi Holland, an associate in Penningtons Manches’ clinical negligence team, who ran the case to conclusion, comments: “Unfortunately, appendicitis can be very difficult to diagnose, especially in its initial stages when its symptoms are commonly, and non-negligently, mistaken for other potential causes, such as gastroenteritis. However, from our experience in dealing with similar cases, experts have confirmed time and time again that certain symptoms should alert any competent doctor to the possibility of appendicitis. An abdominal examination, if carried out appropriately, should confirm or rule out this possibility. The classic symptoms of a patient suffering with appendicitis will usually include abdominal pain which radiates to the right iliac fossa, in the right lower abdomen, a high temperature, vomiting and diarrhoea. On examination, a clinician would typically expect to find abdominal tenderness and guarding in the right iliac fossa. The prevalence of these symptoms usually becomes more obvious in the presence of a ruptured appendix. Typically, once a diagnosis has been made, it is regarded as acceptable practice to perform surgery within 24 hours – depending on the theatre lists that day. However, if there is a suspicion of a ruptured appendix, then surgery is expedited given the significant risks associated with this, including sepsis – which can prove fatal.
“As this case clearly demonstrates, the implications of delayed diagnosis of appendicitis can be very severe, and our client wanted to pursue a claim so as to highlight the issues that arose from her care, in the hope that lessons can be learnt, and that this will prevent future incidents.”
If you or a family member would like advice about a potential claim arising out of delayed diagnosis of appendicitis, please contact the specialist team at Penningtons Manches.