Urethral diverticulum - negligent treatment

And

THE DUDLEY GROUP OF HOSPITALS NHS TRUST

Background to the Claim

JP was 40 years old when, in mid 2004, she noticed a lump in her vagina. The lump was not painful but as her mother had recently had bladder cancer she felt it should be investigated. Her GP thought she may have a prolapse and referred her to a consultant gynaecologist (Mr F) who diagnosed a urethral cyst. Because of its proximity to the bladder Mr F decided not to undertake the operation himself and referred her on to a consultant urologist (Mr E) for treatment.

JP saw Mr E in November 2004 and after examining her he advised surgical removal of what he considered to be a large para-urethral cyst. He told JP that this was a very straightforward operation and possible complications were not discussed. JP was very concerned about prolonged absence from work, as she was a single mother with a small child, and Mr E reassured her that once the catheter was removed after 7 days she would be well enough to return to work.

At operation 3 weeks later (30 November 2004) the supposed cyst was removed resulting in a defect in the urethra which was then sutured. However, the problem was not a cyst on the outside of the urethral wall but a bulging of the urethra itself (a urethral diverticulum) just below the bladder neck.

When the catheter was removed a week later it was noticed that urine was leaking from the vagina. This was due to the presence of a urethro-vaginal fistula (a known complication of this type of surgery) that had developed because of the non healing of the urethral excision. As she had no urinary control whatsoever JP had to wear incontinence pads day and night and she soon became excoriated in the vagina and perineal area.

On 18 January 2005 Mr E undertook a fistula repair using a Martius fat pad technique. Post operatively there was bleeding in the area of the wound and JP had to return to theatre for drainage of a large haematoma.

JP was discharged after 4 days and continued to have pain and discomfort until the catheter was removed 2 weeks later. When the catheter was removed it was obvious that the fistula had not healed as she was still leaking urine. She attempted to keep herself dry by using vaginal tampons and was, understandably, very distressed by her situation.

Things did not improve and in May 2005 she was referred to another urologist (Mr W). A large fistula was confirmed by cystourogram. As Mr W felt that a specialist urologist should attempt a second repair he referred her to Mr C.

JP returned to work after 5 months as she was very concerned about her financial situation but the continuing incontinence made things very difficult and stressful.

On 26 September 2005 Mr C successfully closed the large fistula using the Martius fat technique and JP remained in hospital for 4 weeks with a supra pubic catheter. Unfortunately she was still incontinent post operatively as the repeated surgery close to the bladder neck had affected the sphincter. She continued to have to wear bulky incontinence pads.

Further surgery to rectify the incontinence using an autologus sling to support the bladder took place on 30 May 2006 and, although this was successful in rectifying the incontinence, JP now has retention of urine.

Although no longer incontinent JP now has to regularly self-catheterise to empty her bladder and because of this suffers from recurrent urinary tract infections. She has been advised not to undergo any further urological surgery which means that this situation is permanent.

Particulars of Injury

JP suffered 18 months of pain, discomfort, stress, embarrassment and social isolation following the initial unsuccessful operation. During this time she found it difficult to care for her infant son. She also underwent 3 extra operations in an attempt to rectify the problem and now has to face a lifetime of self catheterisation.

She also suffered a great deal of anxiety over financial matters during this time as she is a single mother totally responsible for a mortgage. She feared she may loose her job as she required so much time off sick.

Case for the Claimant

JP alleged that Mr E had breached his duty of care to her by failing to make a correct diagnosis of urethral diverticulum. Had the correct diagnosis been made some kind of imaging (either MRI or ultrasound) would have been undertaken and JP would have been informed of the possible complications of surgical removal of such a diverticulum, including the development of fistulae, infection and incontinence.

Had she been aware of these risk factors JP would not have consented to the surgery at that time as she had no pain and could go about her daily activities quite normally. Had she had been advised that an operation at some stage in the future was necessary she would have taken steps to make herself more financially secure before proceeding.

Court Proceedings

Liability was initially disputed in the letter of response.

Court proceedings were subsequently issued and the defendant conceded in the defence that it was in breach of its duty in: (a) failing to correctly diagnose a diverticulum; (b) failing to heed urethral involvement of JP's condition; (c) failing to advise JP about the risks of complications resulting from surgery, and (d) failing to obtain JP's informed consent for the operation.

The defendant denied that is was necessary to carry out pre-operative imaging.

The claimant was put to strict proof as to how she would have responded in terms of agreeing to surgery had the risk of urethral vaginal fistulae been explained.

Prior to disclosure of witness evidence the defendant made a Part 36 offer to settle the claim in the sum of £150,000, which JP accepted. CRU in the sum of approximately £15,000 was deducted from this amount.

Legal Representatives

For the claimant

Melissa Gardner

JMW Solicitors

1,Byrom Place

MANCHESTER

M3 3HG

For the defendant

Weightmans Solicitors

1^st floor

St Philips Point

47,Canon Street