Enable Law recently settled a clinical negligence claim on behalf of a disabled widow whose husband died as the result of a series of failings between Bristol University Hospitals and Royal Cornwall Hospital.
Our client was born with VACTERL syndrome, a combination of abnormalities affecting multiple body systems at the same time including the spinal system, the heart, and the kidneys. Due to the nature of this condition, no two patients living with VACTERL syndrome have the exact same symptoms as manifestations can differ a lot from one person to another. In general, VACTERL syndrome is not curable itself, but medics can treat issues linked to the abnormalities it causes. Our client’s VACTERL syndrome manifested in multiple ways with some of the key areas he was being monitored for being his heart and his kidneys. Because of the complexity of the condition, he often needed to visit the specialist heart centre in Bristol with Consultant led care via a clinic at Treliske Hospital and his day-to-day care was managed by Treliske Hospital.
Back in 1994 the treating team suspected that our client had a small hole at the lower chamber of his heart medically known as a VSD (Ventricular Septal Defect) and performed a kidney transplant in May 1994. In 2002, he underwent further tests, including an Echo Cardiogram and ECG for further cardiac investigations. The results of the tests were negative and confirmed no evidence of VSD. He did not require additional treatment. A follow up was not set up specifically for this but because of his overall health condition he continued to be monitored by a medical team.
No further heart concerns were noted until 2014. He was being considered for a further kidney transplant following the deterioration in his kidney function. As part of the assessment, he underwent an echocardiographic study in November 2014 and an aortic aneurysm was noted. However, a VSD was still being listed on the diagnostic list on letter communications despite previous investigations confirming no evidence of VSD. From what we know this study showed again that no VSD was present but unfortunately his test results were lost or not retained as a matter of policy, despite forming part of a patient’s records. This meant that the original study could not be reviewed, and incorrect comments were made on the report. Tragically, the treating team misunderstood the results of both studies, and no questions were raised as to the interpretation of the report meaning an incorrect assumption and diagnosis of VSD was made.
That diagnosis put on hold the cardiac surgery he required as the investigations were ongoing and needed to be resolved with the urgency of our client’s condition being overlooked. There was no clear follow up or surgical plan formulated by the Hospitals. Fast forward to January 2016 and whilst still waiting for final cardiac investigations to be completed our client’s health deteriorated rapidly. Whist doctors realised they had been focusing their efforts in diagnosing a condition he didn’t have, issues with his heart and kidneys escalated causing him to suffer with severe breathlessness from the heart problems he had but had not been appropriately treated, kidney pain and possible sepsis. Sadly, our client did not receive the treatment he needed and died in January 2016.
His wife came to Enable Law trying to find out what had happened in relation to the death of her loved one. She was his primary carer, and he was hers as they both lived with significant health conditions and disabilities. Our team led by Mike Bird, Clinical Negligence Partner and Assistant Coroner requested all medical records and spent a significant amount of time untangling what went wrong with our client’s care. Medical negligence claims are only successful if a claimant can successfully prove that the care received fell below an acceptable level and that directly led to the patient suffering harm over and above what they would have suffered anyway. In this case we needed to prove that if the doctors had not been trying to treat our client for a VSD he did not have and had instead communicated effectively in order to treat his actual heart condition, he would not have died. Following multiple discussions and experts reviewing our client’s medical records, the Trusts accepted liability and settlement was achieved for the case out of Court.
What makes this case really important is that it is yet another example where aspects of someone’s pre-existing condition masked the urgent care they needed to receive. Sadly, we see cases like this very frequently where expert clinicians focus on one possible diagnosis and miss the opportunity to diagnose correctly.
Katy Wood, Associate, working alongside Mike Bird who represented the widow said, ” One of the key issues that came out of the case was the lack of communication between the hospitals that provided our client’s care, meaning his management fell short between Trusts and incorrect treatment decisions were made on missing and misinterpreted test results. “
