A rare complication

BACKGROUND

Ms H is a 54-year-old patient who attends hospital to undergo surgery for the removal of three small kidney stones. A ureteroscopy procedure is carried out by Miss T, a urology specialty trainee, under direct supervision of a consultant. It is expected to be routine as the patient is fit and in good general health.

But partway through the surgery, a ureteral avulsion occurs. Emergency surgery is then carried out by the consultant over several hours to repair the damage.

Ms H is transferred to the high dependency unit for several days before being moved to a ward. She is eventually discharged with a urethral catheter and a follow-up appointment is made.

One month later, Ms H writes a letter of complaint to the hospital about her treatment. She explains that what she believed would be a routine and simple surgery turned into an extremely traumatic event that has left her physically weak, in continuing pain, and facing several months of recovery. She is also unhappy with the response she received from her consultant surgeon who she said seemed evasive when asked about what happened during her procedure.

To inform their complaint response, the hospital launches an investigation and asks Miss T for a statement detailing her involvement in Ms H's care.

ANALYSIS/OUTCOME

Miss T contacts MDDUS and asks a medico-legal adviser (MLA) for assistance in drafting a statement. She explains that the surgery had been uneventful until she attempted to remove the scope and felt some resistance. She says she was advised by the consultant to pull the scope a little more firmly, but it soon became clear that the ureter had avulsed.

Miss T explains that this complication was extremely rare, but not unheard of, for this type of surgery. As soon as the avulsion was discovered, Miss T stepped aside to allow the consultant to proceed with repairing the damage.

Miss T says the day was an extremely difficult one, but she had been reassured by the consultant that nothing could have been done differently to prevent the avulsion. Miss T expressed deep regret for the prolonged pain and suffering Ms H had gone through, for what was expected to be no more than an overnight hospital stay.

The MLA advises Miss T that she should be mindful of her obligation to be open and honest when responding to the complaint, in line with the GMC’s guidance on the professional duty of candour. This may involve considering whether an apology would be appropriate at the outset of the letter of response, bearing in mind that an apology is not an admission of liability. In this situation, where the evidence suggests that nothing could have been done differently to prevent this unusual complication from occurring, it may be that a general expression of regret would be more appropriate and would assist in setting a conciliatory tone.

She should then identify the matters that Ms H is complaining about and explain how she has reviewed her concerns, for example, by considering the records, Miss T's recollections and her usual practice.

The statement should then give a chronology of events (based on these sources of information), detailing the exact timings of what happened and who carried out each action described. She is advised to stick to the facts and avoid any speculation or comments/criticisms of other colleagues. The statement should also avoid any abbreviations or medical jargon.

For the purposes of a complaint response, it could be useful to set out any learning points from the incident, including any personal reflections Miss T may have made. Has she changed her practice in any way in response to what happened? Miss T is also advised she may find it useful to have a more detailed discussion with a colleague to consider what happened during the surgery and why.