4th Annual Multidisciplinary Meeting Risk Management

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4th Annual Multidisciplinary MeetingRisk
Management Medico-Legal Issues in Women's
Healthcare.
Manchester Conference Centre. Wednesday 30th
April Thursday 1st May 03.
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Grainne Barton Partner Clinical Negligence
Alexander Harris Solicitors
CLAIMANT HEALTH LAW SPECIALISTS LONDON NORTH
WEST WEST MIDLANDS
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Chronology of Events 6/2/99 7/2/99

• Time
• 22.24 22.25 Twins Delivered. Uneventful
  caesarean section
  and pregnancy
•  
• 23.00 Back to postnatal ward. In a single
  room.
• B.P on transfer 120/70 on summary of
  labour.
• Laura complaining of headaches on arrival
  (recorded in cardex.)
•  
• Continued on next slide

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Chronology of Events 6/2/99 7/2/99

• 01.35 1ST B.P reading 190/100 when care
  taken over by another midwife.
• Pulse 64.
•  
• 01.40        RMO Visited
•  
• Complaint severe throbbing headache.

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TOUCHE

• asked to see patient complaining of Severe
  throbbing headaches blood pressure 190/100.
  Sudden onset. Temples, no flashing lights/visual
  disturbances. No epigastric discomfort through
  wound.
• Discomfort on arrival Co-Dydramol given for
  headache. On examination in distress. Urine
  protein trace.

Continued on next slide
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TOUCHE

• Blood pressure 200/100, reflexes left right,
  not excessively brisk. No clonus, abdomen
  tender. No epigastric tenderness. Impression
  elevated blood pressure? secondary to
  pre-eclamptic toxaemia or secondary to headache. 
• Plan 1 analgesia, 2 anti-hypertensive
  medication, 3 accurate fluid balance, 4
  quarter hourly observations, 5 pre eclamptic
  toxaemia bloods

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Chronology of Events

• Time
•  
• 02.40            Nifedipine given One to one
  nursing care instituted.
•  
• 03.00 Discussed with anaesthetist
• 03.30             Reviewed by Dr Kean
• Blood patch undertaken
• Continued on next slide

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Chronology Of Events

• 04.10            Blood test results Renal and
  hepatic dysfunction
•  
• 04.20            Slurred speech
• 05.00 Reviewed by Obstetrician.
•  
• Transfer to Middlesex Hospital

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CT scan confirmed a right intracerebral bleed
Transferred to National Hospital of Neurology

• 15th of February 1999
• Laura pronounced brain dead
•  Post mortem undertaken at familys request not
  the Coroners.
• Revealed no aneurysm or arteriovenous
  malformation.

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CORONERS ACT 1988s.8.3(d)

• (8.3)If it appears to a coroner, either before
  he proceeds to hold an inquest or in the course
  of an inquest begun without a jury, that there is
  a reason to suspect
• (d)that the death occurred in circumstances the
  continuance or possible recurrence of which is
  prejudicial to the health and safety of the
  public or any section of the public
• he shall proceed to summon a jury in the
  manner required by subsection (2) above.

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CORONERS ACT 1988S.8(1)

• (8.1) Where a coroner is informed that the body
  of a person (the deceased) is lying within the
  district and there is reasonable cause to suspect
  that the deceased -
• has died a violent or unnatural death
• has died a sudden death of which the cause is
  unknown or
• Has died in prison or in such a place or in such
  circumstances as to require an inquest under any
  other act,
• then, whether the cause of death arose
  within his district or not, the coroner shall as
  soon as practicable hold an inquest into the
  death of the deceased either with or without a
  jury

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REGINA v POPLAR CORONER, Ex parte THOMAS (1992),
WLR 26.03.93 p547

• A 17 year old girl died following a severe attack
  of asthma. An ambulance had been called shortly
  after 1am, but it did not arrive until after
  130am. There was medical evidence that suggested
  that her life would have been saved had she
  arrived at the hospital earlier.
• Coroner refused to hold inquest on basis that the
  deceased had not died an unnatural death within
  the meaning of s.8(1)(a) of the Coroners Act 1988
• The deceaseds mother made an application for
  judicial review of the coroners decision.

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JUDICIAL REVIEW

• Judicial Review allows people with a
  sufficient interest in a decision or action by a
  public body to ask a judge to review the
  lawfulness of
• An enactment or
• A decision, act or failure to act in relation to
  the exercise of a public function.

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Table 3.3 Causes of death to eclampsia and
pre-eclampsia United Kingdom 1985-99
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Cause of Death 1985-87 (n) 1988-90 (n) 1991-93 (n) 1994-96 (n) 1997-99 (n)
Cerebral
Intracranial haemorrhage 11 10 5 3 7
Subarachnoid - 2 0 1 0
Infarct - 2 0 0 0
Oedema - 0 0 3 0
Total Cerebral 11 14 5 7 7

 
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TOUCHE
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CORONERS ACT 1988S.15

• (15.1) Where a coroner has reason to believe
• that a death has occurred in or near his district
  in such circumstances
• that owing to the destruction of the body by fire
  or otherwise, or to the fact that the body is
  lying in a place from which it cannot be
  recovered, an inquest cannot be held except in
  pursuance of this section,
• he may report the facts to the Secretary
  of State.
• (15.2)Where a report is made under subsection (1)
  above, the Secretary of State may, if he
  considers it desirable to do so, direct a coroner
  (whether the coroner making the the report or
  another) to hold an inquest into the death.

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Foreword Jervis

• By the Rt. Hon. Lord Justice Simon Brown
• Over these years, so far from the pace of
  developments slackening in this area of our law,
  it has if anything quickened.
• partly too, I have no doubt, it results from
  what many feel to be the increasingly important
  role played by the Coroners Court in modern
  society.
• there has never been greater need than in
  these explosive days to ensure that tragic
  fatalities are investigated thoroughly and
  independently and brought speedily before a court
  of law. That essentially is what the Coroners
  Court exists to do. And doing it goes a long way
  towards controlling high-running emotions and
  assuaging public anxieties. October 1993

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JERVIS ON CORONERS

• In the second case a 31 year-old woman gave
  birth to twins by caesarean section under spinal
  anaesthetic. Although measured after delivery,
  her blood pressure was not then measured for 2½
  hour period, by which time she had severe
  hypertension, leading to cerebral haemorrhage.
  She suffered a left-sided hemi-plegia, and died 8
  days later. The medical evidence suggested that,
  had her blood pressure been monitored in the
  immediate post-operative phase, her death would
  probably have been avoided.
• Continued on next slide

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JERVIS ON CORONERS

• Her widower sought an inquest, which the
  coroner refused on the grounds that his wifes
  death was not unnatural. The husband applied to
  the High Court for an order requiring the coroner
  to hold an inquest, and succeeded. The coroner
  appealed. The Court of Appeal held that the
  evidence in this case was such that the coroner
  could not properly decide otherwise than that
  there was reasonable cause to suspect that the
  death was at least contributed to by neglect
  (in the technical non-negligence, sense) and
  hence unnatural. But the court also seemingly
  adopted the view that the notion of unnatural
  death encompassed any death, albeit from
  unnatural causes, which was wholly unexpected and
  resulted from a culpable failure. This decision
  represents the current view of the higher
  judiciary upon the subject.

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HOW TO AVOID LITIGATION

• Communication with staff and patients.
• Thorough recordings of investigations and thought
  process.
• Learning from mistakes and correcting systems
  where they have failed.
• Early senior involvement if warranted.
• Review of staffing levels on danger days.
• Encouraging incident reporting.
• Hold your hands up apologise