Medical negligence claim and DVT

Medical negligence case report

CB

And

NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS TRUST

Background to the medical negligence claim

In 2001 when CB was 46 years old she developed a deep vein thrombosis (DVT) in her left leg. This progressed to a pulmonary embolus (PE) and she was admitted to hospital and anticoagulated. She then took Warfarin for a further six months.

She had two further admissions in 2004 and 2005 for suspected DVTs but scans and D-dimer tests on both occasions were negative.

CB had been experiencing pain in her left knee for some time and in 2005 her GP referred her to an orthopaedic consultant (Mr M) who diagnosed tri-compartmental osteoarthritis and recommended a total knee replacement.

In July 2006 she attended a pre-admission clinic and her past history of DVT and associated pulmonary embolus was noted. This put her in the high risk category for a thromboembolitic event. It is the trust's policy to give Warfarin for three months post-operatively to high risk surgical patients, but this somehow got overlooked in CB's case.

On 18 August 2006 CB underwent a left total knee replacement and, although it stated clearly in her pre-op medical history that she had saphenous incompetence and had had a previous DVT and PE, she received no pre-operative prophylactic anticoagulation. Post-operatively she received Tinzaparin (a low molecular weight heparin) for five days, but Warfarin was not given.

Two months later, on 28 October 2006, CB collapsed at home with sudden onset of dizziness and shortness of breath. She was admitted to hospital where a diagnosis of pulmonary embolus, secondary to a DVT, was made. She then suffered a respiratory, possibly also cardiac, arrest and was rapidly resuscitated before being admitted to ICU where she remained for three days. A CT scan showed a massive PE. She received thrombolysis and anticoagulation and gradually recovered and was discharged on 8 November 2006.

Case for the claimant

CB has been left with a very painful and swollen left leg and foot that considerably restricts her mobility. She claims this is a direct result of the DVT of October 2006, rather than the surgery itself or the previous DVT, and is likely to be long term. She takes pain killers most of the time and requires adjustable footwear because of the swelling. She now has a post-phlebitic syndrome of the left leg making her prone to further attacks of DVTs and increasing her risk of developing ulceration at the ankle in the future. Also she must now remain on continuous life-long anticoagulant therapy with Warfarin.

CB alleges that, had the hospital protocol for anticoagulation therapy for high risk patients undergoing orthopaedic surgery been followed, she would have received Warfarin for three months post-operatively, rather than five days of Tinzaparin. If this had occurred, on the balance of probabilities, she would not have developed the DVT or the pulmonary embolus and, therefore, would not now be disabled by the pain and swelling in her leg, which greatly affects her mobility and quality of life.

Following the trauma of the pulmonary embolus and the sudden collapse, CB has developed a mild/moderate post traumatic stress disorder, although it is not expected to extend beyond about two years. She has also developed a mild/moderate adjustment disorder for which cognitive behavioural therapy has been recommended.

CB also developed increasing pain in her right knee as a result of arthritis (unconnected with the admitted negligence) for which knee replacement surgery had been considered but seemingly had been ruled out because of the high risk of developing a further DVT. Although CB had been described as obese prior to the events giving rise to this claim, she had embarked on a weight loss programme and was successfully losing weight.

However, because of the enforced immobility due to both the arthritis in her knees and the pain and swelling in her leg following the DVT, she put on a considerable amount of weight. As a consequence of the constellation of her symptoms, causation was a particularly complex issue, resulting in difficulties in quantifying the claim.

Case for the defendant

There was no attempt to defend this case and the defendant admitted – "that the ordinary practice would have been to provide Warfarinisation (with regular blood tests) for three months. It was therefore inappropriate to have provided thrombo-prophylaxis for five days. On the balance of probabilities, if the claimant had received Warfarin for a period of three months post-operatively, she would probably have not developed a massive pulmonary embolism". No further admissions were made on causation with regard to CB's current symptoms.

Damages

The NHSLA dealt with this case in-house and at a very early stage made an offer of £10,000, which was rejected. Following disclosure of expert reports from a vascular surgeon, a respiratory physician and a psychologist plus a preliminary schedule of loss, the parties agreed to jointly instruct an orthopaedic surgeon to consider the issue of causation and in particular whether CB was precluded from undergoing further knee replacement surgery. Prior to the instruction of the orthopaedic expert, an offer of £100,000 was made and was accepted.

Legal representatives

For the claimant

Sally Leonards
JMW Solicitors LLP
1, Byrom Place
Spinningfields
Manchester M3 3HG

For the defendant

David Gurusinghe
Solicitor/Case Manager
NHS Litigation Authority.

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