Miss J v North Middlesex Hospital NHS Trust

Miss J arrived home from school on 2 January 2013 whereupon she started to feel unwell. Shortly thereafter she began to develop severe abdominal pain along with diarrhoea. The problem persisted for three days and on 5 January 2013 she attended the hospital complaining of vomiting and severe abdominal pains, followed by diarrhoea and nausea. No investigations were carried out. Dysmenorrhea (painful menstruation, typically involving abdominal cramps) was diagnosed, and she was sent home. On 7 January 2013 she attended A&E again where it was noted

“alert, crying++, appears to be in a lot of pain, cramping pain… Primary diagnosis – gastrointestinal.”

On 11th January 2013 Miss J was admitted into hospital. She was severely ill with peritonitis from a perforated appendix. A laparotomy showed a perforated appendix, with peritonitis and pus in the abdomen. She remained in hospital for 19 days, and remained off school for two months and consequently she did not feel emotionally better for about a year.

We obtained a liability report from an expert in Emergency Medicine. Our expert was very critical of the Trust’s management of Miss J condition on the 5th and 7th January 2013.

Our expert found that Miss J’s first attendance on the 5 January 2013 was not supported by the history provided by her medical notes or the presenting vital signs from Miss J on this date. The indications of the symptoms the Miss J was presenting with indicated a gastrointestinal cause rather than Trust’s diagnosis of dysmenorrhoea. Our expert was also critical of the fact that no blood tests were ever conducted for Miss J and therefore a full investigation was never completed before discharge she was discharged home. Miss J therefore re-attended 2 days later to the Emergency Department after her symptoms had substantially deteriorated.

Our expert pointed out that it was well recognized that a second attendance to an Emergency Department within a short period of time i.e. 2 days often indicated that there is a serious underlying condition and in his view that the care received by Miss J fell below the reasonable body of practitioners as no blood tests were indicated nor conducted and therefore until the results of these investigations were known her discharge was unsafe.

From the point of view of causation, we asked an expert colorectal and trauma surgeon to comment on what the position would have been if the appendicitis had been diagnosed on 5 January and on 7 January. Our expert said:

“Had there been no negligence, Miss J would probably have undergone surgery for her appendicitis on the 6th, “she would have made an uneventful recovery and been discharged from hospital on the following day and would not have suffered any of the complications she did. She would have returned to school after 1—2 weeks, and normal activities after 4 weeks.”

Our expert added that it was not necessary to consider what would have happened had the problem been identified on the 7th, because it ought to have been identified two days earlier. For what it is worth, however, she would have made an equally good recovery, though it would have taken a little longer. Most importantly, however he concluded that:

• Had there been no negligence, Miss J would probably have undergone surgery for her appendicitis on the 6th, “she would have made an uneventful recovery and been discharged from hospital on the following day and would not have suffered any of the complications she did. She would have returned to school after 1—2 weeks, and normal activities after 4 weeks.
• She would have avoided a midline incision. She would have avoided the severe sepsis and admission to the paediatric high dependency unit.
• She would have avoided the prolonged pain and suffering whilst on the PICU and the hospital stay of 19 days. She would have avoided the need for a percutaneous drainage of intra-abdominal collection. She would have avoided the pleural effusions and basal lung consolidation. She would have avoided the superficial wound infection in her midline wound.
• She would have avoided the psychological disturbance associated with the trauma of a severe illness.
• She would have avoided the subsequent hospital admission with abdominal pain and vomiting, which on the balance of probabilities was caused by an early adhesive small bowel obstruction.
• She would have avoided the severe weight loss and debility with weakness.
• She would have avoided the additional radiological exposure of a CT scan.

Miss J eventually made a good physical recovery but:

1. She was left with an ugly midline scar measuring 13 cm × 15 mm and also pale scars from the stapling after surgery. Surgery reconstructive could improve the main scar somewhat, but not remove it altogether;
2. There was a 20% lifetime risk of developing an incisional hernia, with a 30% risk of a recurrence. An incisional hernia would also lead to a further scarring;
3. The appendicitis caused adhesions as well as a 15% risk of further adhesions, and a 1% risk that she would have to undergo surgery. The worst outcome – intestinal strangulation – carried a 0.02% risk, though if it materialised, there was a mortality risk of 8—15%;
4. She had developed post-traumatic stress disorder;
5. There was also a significant risk that Miss J’s fallopian tubes had been damaged, and that she would have difficulty in conceiving.

Defendant Trust denied liability. Given the overall litigation risk the claim was eventually settled in the sum of £65,000 and this is broken down as follows:-