Penningtons Manches’ clinical negligence team has settled a claim for £2.16 million for a client who will now require a small bowel transplant as a result of negligent care at Croydon University Hospital.
At approximately 8am on 26 June 2012, the client was admitted to the accident and emergency (A&E) department at Croydon University Hospital by ambulance. She had been suffering from a sudden onset of severe abdominal pain on her left side since the previous day. The ambulance records noted that her reported pain was 8-9 out of 10, and was so acute that she had been found on her knees leaning against the sofa. Blood tests were performed as well as an intravenous urogram (to test for kidney stones), which was reported as normal. She continued to suffer severe pain which failed to respond to strong painkillers. It was noted that she had undergone bariatric surgery in the past. No diagnosis was made, and she was discharged that afternoon without any further investigations.
In the early hours of 27 June, the pain was so intense that she re-attended the A&E department. The intravenous urogram from the previous day was reviewed and this time interpreted as abnormal. The client was referred to the surgical team, although she was not seen for a further five hours, during which time she was still in extreme pain. She was eventually examined by a junior member of the surgical team, who found no abnormalities. She was given morphine for the pain and kept in for observation.
An ultrasound scan was performed on 29 June, but this was reported to be inconclusive. In the early hours of 30 June, the client’s condition took a turn for the worse. A CT scan was performed, which demonstrated a twisted small bowel and she was taken to theatre for emergency surgery. Surgeons found that the entire length of the small bowel had become necrotic due to a lack of blood supply, and had to be resected. During the course of a further operation on 2 July, her gallbladder was found to be distended and necrotic, and had to be removed.
The client remained in a critical condition in the intensive care unit. She was transferred to St George’s Hospital on 24 July for further specialist surgical and intensive care. The client underwent surgery again on 14 August to remove her spleen and part of her stomach, which had also become necrotic. Following a slow and steady recovery, she was discharged in December 2012 with a PICC line in place to deliver total parenteral nutrition (TPN) intravenously. The client was subsequently referred to the intestinal failure and small bowel and intestinal transplant team at Addenbrooke’s Hospital, Cambridge. In 2013, she underwent further operations to create a small gastric pouch and join up the remaining bowel, allowing her to eat and drink small amounts. She was told by her treating doctors that it was a medical miracle she had managed to survive her ordeal.
The client now remains on TPN, delivered through her PICC line. She manages this by herself at home, but the absence of a suitable sterile environment increases the risk of recurrent infection. Each time this occurs, she must be immediately admitted to hospital where she is placed on intravenous antibiotics. The infections often result in the need to re-site her PICC line, and she is running out of viable veins to do so. She is likely to become imminently eligible for an intestinal transplant, due to the frequency and severity of her line infections. This will involve a hugely invasive procedure with a long and potentially difficult post-operative recovery period. She will require life-long treatment with immunosuppression medicines and have a higher lifetime risk of developing infections as well as some cancers related to her transplant.
As a result of her injury, the client’s bladder and bowels have been severely affected, and anything she eats or drinks passes straight through her, meaning she often has accidents and has to wear incontinence pads. She also suffers from chronic exhaustion and intermittent, chronic stomach pain and nausea on a daily basis. When walking any distance she becomes unsteady on her feet, and is prone to tripping. She has been left with extensive abdominal scarring from the numerous operations she has had to undergo, and is extremely self-conscious about the extent of this scarring which reminds her of the traumatic events she underwent. Following her lengthy hospital stay, she suffered flashback of the events, particularly of times when she feared she would die. She developed post-traumatic stress disorder and depression.
Penningtons Manches was first instructed to investigate the potential claim against the hospital trust in March 2015. The client was advised to pursue a legal action by her treating doctors. Once instructed, the clinical negligence team obtained the client’s medical notes and records. As the expiry of the primary limitation period was approaching, a protective claim form was issued in June 2015. The defendant trust was asked to consent to an extension of time for service of the particulars of claim, but this was refused and the Penningtons Manches team was forced to issue an application to court. Subsequently, an extension until 30 January 2016 was granted for the service of court proceedings.
An expert in general surgery was instructed to consider and report on the standard of treatment received while the client had been under the care of the surgical team, and to what extent this led to the need for extensive surgery. It was the expert’s opinion that the client had attended A&E with classic signs of acute ischaemia (lack of blood supply) of the bowel, namely very severe abdominal pain, failure to respond to analgesia, and lack of abdominal findings, out of proportion to the pain she had complained about, and therefore an earlier CT scan should have been mandatory. This would have led to urgent surgery which, on the balance of probabilities, would have resulted in a resolution of the problem without necrosis of the bowel.
Following receipt of the general surgeon expert’s supportive report, an expert in A&E medicine was instructed to comment on the standard of treatment afforded while the client was under the care of the A&E team. The expert was initially unsupportive of the case, and following an initial conference with counsel, it was decided to obtain a further expert view. Another report was obtained which was supportive.
Proceedings were served on the defendant in January 2016. The defendant was delayed in serving its formal defence, and was given several extensions of time. In July 2016, full liability was admitted. Given the admission, Penningtons Manches’ clinical negligence team was able to secure an interim payment of damages of £50,000 for the client.
A court timetable was put in place, and the case was listed for a five day trial in January 2018 to determine the level of damages. Over the following months, both parties proceeded to obtain evidence from experts on the client’s condition and prognosis, for the purposes of quantifying the claim. Experts in transplantation surgery, occupational therapy, nursing and psychiatry were instructed.
During this time, the client continued to suffer from recurrent infections to the site of her PICC line, requiring hospital admissions. She was told that once her entire venous system became compromised, she would require a bowel transplant as a life-saving operation. Initially the clinical negligence team investigated the possibility of her travelling overseas for a transplant, but a transplant expert advised that her needs would best be served under the care of the NHS Transplantation Unit at Addenbrooke’s Hospital in Cambridge. Expert evidence suggested that bowel transplant surgery should only be undertaken as a last resort, given the inherent risks and complications associated with the procedure and the post-operative recovery period. Statistics show that approximately 20% of patients do not survive the first year following an intestinal transplant. The average survival time for a patient who has survived the first year is around 10 years, and the overall long-term survival rate for young adult patients is approximately 55%.
Further expert evidence recommended that the client required immediate nursing care to manage her PICC line and TPN. She also needed childcare for her eight year old son. The client was advised to relocate to Cambridge once she had been put on the transplantation waiting list, in preparation for the difficult recovery period during which time frequent hospital appointments would be required. Following this period, it was recommended that she move to a four bedroom property in London, with room for a live-in carer and live-in nanny.
Once both parties’ expert evidence had been served, key areas of dispute included the client’s care and accommodation requirements, as well as her ability to work following a transplant. The defendant suggested that the client’s personal care and childcare needs could be met by a ’nanny housekeeper’ who would attend to both her and her son. Nursing care evidence obtained by the Penningtons Manches team strongly set out that this scenario would jeopardise the client’s health, and that her care needs could only be met by a specialist nurse.
A joint settlement meeting took place in December 2017, during which the Defendant rapidly put forward generous offers, significantly higher than those in its counter-schedule of loss. The Penningtons Manches team was finally instructed by the client to accept a lump sum of £1.35 million, with annual payments of £65,000 until 2024, and of £30,000 thereafter for the remainder of the client’s life. At the conclusion of the settlement meeting, leading counsel for the defendant expressed her sincere condolences for the client’s predicament.
At the outset, the claim was led by London-based clinical negligence partner, John Kyriacou, and once liability had been admitted, the claim was managed by associate Rosie Nelson. She commented: “We are delighted to have achieved this outcome for such a deserving client who has been through a considerable ordeal. Although obviously nothing can compensate her for what has happened, we hope that this significant settlement will allow her to move on with her life as best she can.”