Knee surgery
Claims relating to knee surgery were often brought with respect to:
In many claims, it was alleged that the surgical technique was negligent, but another frequently occurring theme was alleged failure to obtain informed consent. When consent was found to be inadequate, the most common factors were a failure to offer conservative management as an option or to explain the limitations of the proposed procedure (including that it may not completely relieve pain or fully restore mobility). Further allegations related to pre-operative discussion were failure to inform patients of the likely longevity of a total knee replacement. Where claims related to negligent technique, the following allegations were identified:
A number of claims were brought with respect to post-operative wound infection, including failure to manage diabetic control adequately leading to increased risk of infection. Other practitioners such as GPs and district nurses may also be named in such cases, but it is recommended that orthopaedic surgeons should ensure that follow up arrangements are adequate, and concerns raised in the community about potential wound infection are taken seriously. Our highest knee surgery total case payment was in excess of £2 million.
Hip surgery
The majority of claims received in relation to hip surgery involved elective total hip replacements. The allegations included:
Alleged negligent outcomes included leg length discrepancy, pain and stiffness, restriction of mobility, nerve damage, infection, or dislocation. Many patients who claimed had required additional correction surgery.
As seen in claims relating to knee surgery, allegations that informed consent was not obtained were commonly seen. Claims were also brought with respect to post-operative wound infections, leading to the requirement for long-term antibiotics and revision surgery.
Of the claims settled on behalf of Medical Protection members, the highest total payment was in excess of £500,000.
Metal-on-metal hip implants
Allegations relating to metal-on-metal hip implants formed a very small minority of hip surgery claims.
Allegations directed at Medical Protection members included ‘mixing and matching’ of components from different manufacturers. This was alleged to lead to increased metallosis or the accumulation of metal debris in soft tissues. The contributing factors leading to claims were failure to inform patients of the risk of developing an adverse reaction to metal debris, failure to monitor metal levels in the blood, failure to perform imaging, and failure to offer revision surgery in a timely manner.
Spinal surgery
In our analysis, spinal surgery procedures were undertaken by either neurosurgeons or orthopaedic surgeons. Where the surgery was performed by an orthopaedic specialist, claims often related to lumbar nerve root decompression or spinal fusion. Common allegations in clinical negligence claims relating to spinal surgery were that the choice of procedure was incorrect or unnecessary, or the surgical technique was poor.
The consequences for the patients were either ongoing symptoms of pain and weakness, leading to significant dissatisfaction, or development of new, more troublesome symptoms, including bladder and bowel incontinence, and foot drop. Some claimants required additional surgery. The highest total claim payment in relation to spinal surgery was almost £400,000.
When consent was found to be inadequate, the most common factors were a failure to explain that symptoms may not improve or may even get worse. The risk of developing new, and potentially life-changing, symptoms was often also not clearly discussed, and failure to offer conservative management as an option was also a factor. The Getting It Right First Time (GIRFT) report on spinal services produced in January 2019, supports the notion that a lack of fully informed consent plays a role in many claims.
The British Association of Spinal Surgeons (BASS) has produced useful information for patients undergoing lumbar discectomy and decompression, and can be found at British Association of Spine Surgeons - Lumbar Discectomy and Decompression, but this does not remove the need for the surgeon to ensure they have fully discussed the potential benefits and risks of the procedure specific to each patient.
Hand surgery
A number of claims were made in relation to hand surgery. We found the most common factor was when trigger finger release, Dupuytren’s contracture release, ganglion excision, and carpal tunnel surgery were performed in a one-stop setting where the discussion and consent for the procedure and the surgery itself took place on the same day.
Claims were often settled on the basis of a failure to discuss the available options. In some circumstances, the operating surgeon had made the incorrect assumption that conservative management had already been discussed with the patient by the referring clinician, usually a GP, and therefore did not discuss the non-operative options available to the patient.
Where a claim was then brought following an adverse outcome, the claimants were in a position to allege that had they been made aware of the potential for non-operative management, they would have opted to pursue this first. In addition, allegations were made in relation to poor surgical technique, resulting in consequences such as nerve injury, leading to loss of function of the hand. In a number of cases, further surgery was required in an attempt to resolve complications arising from the initial procedure. Of the claims settled, the highest total payment was in excess of £200,000.
Foot surgery
Several claims were made in relation to hallux valgus correction surgery. These included tendon and nerve damage, resulting in complex regional pain syndrome and abnormal gait. When consent was found to be inadequate, the most common factors were that the risks of chronic pain or neuropathic pain were not discussed before surgery.
Shoulder surgery
A small number of claims were made in relation to shoulder surgery, and the common theme was alleged negligent surgical technique leading to ongoing or worsened pain and lack of mobility, tendon damage, and bursitis.
Fractures
In our analysis, there were claims of missed fractures around total hip prostheses. Some of these occurred following falls in the private hospital setting shortly after joint replacement surgery. In some claims, the orthopaedic surgeon did not adequately examine the patient or arrange further imaging after the fall or prior to discharge, despite concerns raised by the patient or by allied health professionals in relation to pain or mobility.
Other claims were made in relation to failures to recognise non-union of fractures, or allegations of negligent surgical technique resulting in nerve damage.