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Perfection is Not a Standard

posted 2 years ago

This case involves a 30-year-old man who developed a gradual onset of acute abdominal pain over 24 hours, associated with some vomiting and diarrhoea. He presented to hospital at 16:30 hours with a normal pulse and temperature. A CT scan was requested, which was carried out at 19:00 hours. He was diagnosed as having appendicitis and placed on nil by mouth and intravenous antibiotics to await appendicectomy on the emergency list. Unfortunately, a number of other emergencies presented that night so that his operation could not take place until 13:00 hours on the day after his admission.

An acute gangrenous appendicitis was noted at surgery with no surrounding abscess. The appendix was easily mobilised and removed. He remained in hospital on antibiotics for a further four days and was then discharged, making an uneventful recovery.

The plaintiff took a case claiming that his surgery had been delayed, allowing his appendix to go gangrenous and causing him to remain in hospital three or four days longer than would otherwise have been the case.

Recently, there have been a number of clinical trials in cases of proven acute appendicitis, whereby patients were treated with intravenous antibiotic therapy and no initial surgery. This has had limited success, but there is a reasonable school of thought that if, having been given the antibiotics intravenously, the patient gradually responds with a decrease in pulse, temperature and pain, then it is a reasonable course to continue. If, however, the pain does not start to recover within a matter of hours, then an appendicectomy, either open or laparoscopic, is required.

There is also, on the basis of reports from the Colleges of Surgeons (CEPOD), a strong recommendation that surgery is not carried out through the night, particularly after midnight, and it is regarded as reasonable to treat a case of acute appendicitis with antibiotics through the night and delay operation until the following day. This has been shown to be a much safer approach in the emergency care of patients, in that there are full operating and nursing teams available during the day. 

In the subject’s case, the surgery was delayed by emergency operations until after midnight. The patient was given intravenous antibiotics and the appendix removed at the earliest possible opportunity, which was the following afternoon. The tip of the appendix was gangrenous, but there was no evidence of any abscess formation, and the patient made an uneventful recovery although was detained for several extra days in hospital until they were sure no further infection would arise.

The practice in this case, although not “ideal” or “perfect”, would be regarded as being reasonable in the circumstances.

It is important to remember that a patient is not entitled to “Rolls-Royce care” but a reasonable standard, taking into account all the prevailing circumstances, including the use of emergency theatres. Perfection is not a standard but an aspiration. An average, reasonable standard is what can be demanded, and this needs to be clearly elucidated before an action in negligence is contemplated.

MDU figures for 2021 show that fewer than one in six actions in medical negligence actually succeed, with the vast majority failing on the grounds of causation. It must be remembered that subsequence is not the same as consequence.

Initial screening is, therefore, essential to manage client expectations at an early stage. This avoids unnecessary effort and costs for all concerned. Too many cases are taken to Court with no chance of success. This is stressful for both the client and their legal adviser, and indeed for the medical personnel involved.

For fast and effective screening of all potential medical negligence cases, contact Peyton Medico Legal Services now on +44 (0)28 87724177 or email [email protected]


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