Joseph Raine

An analysis of successful litigation claims in children in England

Objective To analyse the number of successful claims against the National Health Service (NHS) involving children, the nature and outcome of incidents leading to litigation and the costs of claims. Method Under the Freedom of Information Act, details were sought of claims involving children made to the National Health Service Litigation Authority (NHSLA) from 1 April 2005 to 31 March 2010 together with the claim status on 30 September 2010. Closed cases involving financial compensation were analysed in relation to the nature of the incident, outcome and total cost of litigation. Results 195 closed cases were examined. The commonest causes of litigation were medication or vaccination errors (10), delayed septicaemia diagnosis (8), delayed meningitis diagnosis (7), delayed unspecified sepsis diagnosis (7), extravasation (7), delayed anorectal abnormality diagnosis (6), delayed cardiological diagnosis (6), delayed appendicitis diagnosis (6), epilepsy misdiagnosis (6), psychological/psychiatric effects on parent(s) following a medical error (4), delayed fracture diagnosis (4), gastrostomy related errors (3) and delayed testicular torsion diagnosis (3). The commonest outcomes were death (74), unnecessary pain (35), unnecessary operation (16), brain damage (12), scarring (12), psychiatric/psychological morbidity in parent(s) and/or child (10) and amputation (5). Total costs of litigation ranged from £600 to £3 044 943 (mean £127 975). Conclusion Delayed diagnosis of severe sepsis is the commonest adverse incident leading to successful litigation and the commonest adverse outcome is death. The cost to the NHS is considerable. A better understanding of the causes of common errors in paediatrics should inform training and help to decrease these adverse events.

Continuous negative extrathoracic pressure and cardiac output--a pilot study.

Continuous negative extrathoracic pressure (CNEP) has been recently reintroduced as therapy for respiratory failure. To determine its effects on cardiac output a pilot study was performed in ten patients aged 2 months-3 years (meadian 4 months). All had chronic respiratory failure (seven with bronchopulmonary dysplasia). Five were breathing spontaneously and five were intubated and undergoing intermittent positive pressure ventilation. Transcutaneous oxygen saturation andPCO2, together with ECG were continuously monitored. Pulmonary artery blood flow velocity was measured noninvasively using pulsed wave Doppler. The 95% confidence intervals for the changes with and without CNEP in spontaneously breathing and ventilated patients showed no statistically significant changes in heart rate, O2 saturation, transcutaneousPCO2 or cardiac output. This study shows that the use of CNEP, administered in a tank respirator, does not lead to large changes in cardiac output.

Corneal rupture in a child with Down syndrome and hyperthyroidism

The present report describes the clinical findings in a rare case of a child with trisomy 21 and hyperthyroidism, who developed severe acute hydrops with corneal perforation secondary to underlying keratoconus. There is a known association between trisomy 21 and keratoconus (a conic protrusion of the cornea),1 and children with trisomy 21 are also at increased risk of developing thyroid disease, including thyrotoxicosis with exophthalmos.2,3 However, a paediatric case with dual underlying diagnoses of trisomy 21 and hyperthyroidism, who subsequently developed severe hydrops, has not to our knowledge been previously described.

Growth Hormone With Aromatase Inhibitor May Improve Height in CYP11B1 Congenital Adrenal Hyperplasia

With an estimated prevalence of 1 in 100 000 births, 11β-hydroxylase deficiency is the second most common form of congenital adrenal hyperplasia (CAH) and is caused by mutations in CYP11B1. Clinical features include virilization, early gonadotropin-independent precocious puberty, hypertension, and reduced stature. The current mainstay of management is with glucocorticoids to replace deficient steroids and to minimize adrenal sex hormone overproduction, thus preventing virilization and optimizing growth. We report a patient with CAH who had been suboptimally treated and presented to us at 6 years of age with precocious puberty, hypertension, tall stature, advanced bone age, and a predicted final height of 150 cm. Hormonal profiles and genetic analysis confirmed a diagnosis of 11β-hydroxylase deficiency. In addition to glucocorticoid replacement, the patient was commenced on growth hormone and a third-generation aromatase inhibitor, anastrozole, in an attempt to optimize his growth. After the initiation of this treatment, the patient’s growth rate improved significantly and bone age advancement slowed. The patient reached a final height of 177.5 cm (0.81 SD score), 11.5 cm above his mid-parental height. This patient is only the second reported case of the use of an aromatase inhibitor in combination with growth hormone to optimize height in 11β-hydroxylase-deficient CAH. This novel treatment proved to be highly efficacious, with no adverse effects. It may therefore provide a promising option to promote growth in exceptional circumstances in individuals with 11β-hydroxylase deficiency presenting late with advanced skeletal maturation and consequent short stature.

Openness and honesty when things go wrong: the professional duty of candour (GMC guideline)

In June 2015, the General Medical Council (GMC) and Nursing and Midwifery Council (NMC) jointly published the guidance Openness and honesty when things go wrong: the professional duty of candour. 1 This guidance was developed in response to the Francis report about the Mid Staffordshire NHS Foundation Trust.2 It elaborates on the joint statement from eight regulators of healthcare professionals in the UK about the professional responsibility of all healthcare professionals to be honest with patients when things go wrong.3 The guidance builds on the principles set out by the GMC in Good Medical Practice and by the NMC in The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives .4 ,5 It is guidance for individuals meaning that even if you are not the person reporting adverse incidents and speaking to patients if things go wrong, you must make sure that someone in the team has taken responsibility for this and support them as needed. This guidance applies to all doctors registered with the GMC across the UK. In addition, there is now a statutory duty of candour, meaning a legal obligation, for NHS organisations within England as well as independent health and social care providers. This follows the Health and Social Care Act, which came into force in November 2014. Different laws apply in other parts of the UK. The Francis report is explicit that any patient harmed by the provision of a healthcare service is informed of the fact and offered an appropriate remedy, regardless of whether a complaint has been made or a question asked about it. The statutory duty of candour applies when a patient has been subjected to moderate harm or worse, as a result of an error. Cases where an error has led to severe harm or …

Which errors do the medical defence organisations most frequently report

Errors are a very important source of learning for doctors and nurses. Professor Sir Liam Donaldson in the government publication ‘An Organisation with a Memory’1 stressed the importance of health professionals and medical institutions learning from their mistakes. This included learning from medical litigation. The three Medical Defence Organisations (MDOs) in the UK all publish journals every few months or annual reports, which contain case reports from the different specialities. These case reports are based on real claims. They are annonymised to preserve confidentiality and are …