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In part 1 of this article, published in Issue 5 of Medico- Legal Magazine, I introduced common reasons for medico-legal claims in this specialty, including: the precise determination of the presence of injuries, missing treatable injuries, pre-existing problems, interpreting injuries and delays in diagnosis.
In the second part of this article, I will discuss the impact of NHS targets on treatment of facial trauma, as well as other issues such as patient consent, confidentiality and compliance, which could all arise in litigation.
6. Treatment in a timely fashion within the confines of NHS targets.
Unlike cancer treatment, there are currently no universally accepted targets within which injuries can be left safely before treatment becomes necessary. The exceptions to this are the management of the knocked out tooth and a few other rare emergency conditions. With all other injuries it is often a matter of opinion, and these differ. This may be reflected in disagreements between specialists in medical reports.
Furthermore, acceptable ‘times to treatment’ may conflict significantly with other NHS ‘targets’. For instance, whilst the management of most facial fractures can be safely deferred several days or longer if necessary, successful management of the avulsed (knocked out) tooth is much more time dependant - there is good evidence to suggest that this should be replaced within 1 hour of injury. Yet current waiting time targets in A&E are up to 4 hours. Considering the nature of life / limb and sight-threatening injuries and medical emergencies that most A&E departments regularly contend with, it can be hard to justify or ensure any policy that dictates that the patient with an avulsed tooth should always ‘jump the queue’. Similarly, urgent outpatient CT scans in facial trauma should enable treatment to be undertaken within a few days of injury, yet a two week delay (acceptable for ‘cancer’ patients) is often regarded as an acceptable standard for trauma.
Our ability to treat patients in a timely fashion is also greatly influenced by the pressures on the entire service and whilst all injuries should ideally be managed within relatively short deadlines the justification for relatively minor injuries to be expedited to the detriment of urgent cases, cancer patients and ‘long waiters’ can at times be difficult. Delays are therefore often unavoidable.
An especially difficult problem is the uncooperative patient (often a child) who requires a general anaesthetic to replace a knocked out tooth. Parents may attend with expectations of immediate treatment. However, current guidelines or a lack of fasting may result in refusal of a general anaesthetic late at night, for a non ‘life or limb threatening’ condition. This will inevitably lead to a significant delay and increased risk of loss of the tooth.
7. Lack of “Specialist” care
Not all fractures require surgery. The decision to operate is made jointly between the patient and surgeon, following careful assessment and weighing up the risks and benefits of treatment. However, on occasion patients attend expecting an operation, having been told they will need one. They may then be somewhat affronted when they are told that in fact, they do not and this undermines confidence. Referring practitioners should always refer for an “opinion”, not for an operation.
Furthermore, not all facial injuries, notably lacerations, need to be referred to a ‘specialist’. But this is increasingly becoming an expectation. However, the reality is that even if referred to a specialist service, the patient may not necessarily be treated by the most senior member of the team - facial lacerations and many simple fractures are often repaired by trainees, not consultants. That said, outcomes are dependant on an individual’s competencies and not the simple fact that they are a ‘specialist’, or consultant. Excellent outcomes are quite achievable by ‘non specialists’, including nurses trained in suturing. Indeed, not all facial surgeons regularly manage or have an interest in facial trauma. Thus a referral to a specialist is no guarantee of outcomes. That said, as clinicians it beholds us to always work within our sphere of competencies and refer on if necessary.
8. Consent issues
Obtaining ‘appropriate’ informed consent can often be problematic. Current guidance is somewhat vague and it is left to the discretion of the consenting clinician as to what should be discussed. Terms like ‘common’ and ‘severe’ are poorly defined and are a matter of personal opinion, particularly now with the Montgomery ruling. This is open to exploitation as it is clearly not possible to discuss every conceivable complication that may occur during surgery. For example, even a simple skin incision can be complicated by pain, swelling, bruising, wound breakdown, infection, haemorrhage, unfavourable scarring, stretching, increased pigmentation, loss of pigmentation, numbness, weakness, damage to underlying structures....all of which can be a subject to the Montgomery rule - and that’s just the incision!
Some complications are so rare that they may not be recalled during the consent process. Furthermore, when patients ask ‘what’s the risk?’, the figure quoted is usually that which has been published in the literature. Of course, what they really want to know is ‘what’s the chance of this complication occurring in the hands of the surgeon who will be operating?’ - something that is impossible to know.
Not surprisingly then, some consent forms may be considered to be lacking when it comes to litigation. For example, blindness, skull fractures and even some rare but serious brain-related complications, have all been reported following routine nasal surgery. Similarly, ‘avascular necrosis’, with partial loss of the jaw or its teeth has also been reported following injuries and elective surgery. Permanent discolouration of the eyelid can occur following injury or surgery. Such complications are as rare as the proverbial ‘Hen’s tooth’, but nevertheless potentially devastating for the patient - one would think. Yet interestingly, I have encountered patients where loss of sight in one eye has not been considered serious, on the basis that they have two! On the other hand, eyelid discolouration or the loss of a tooth may be considered a major complication in other patients. Failure to restore the patient’s appearances precisely is also difficult to guarantee - there will often be some residual stigmata, which they may not be happy with.
Consent is therefore a major medicolegal headache, which requires extensive, careful, full and often frank discussion with the patient and sometimes other interested parties. Just like crossing the road, we have to accept the risk of a devastating outcome - we could be hit by a car. Surgery is the same. All precautions are taken, but some risks remains. Nobody dies from an isolated broken nose, but in theory at least they could if they have an operation to straighten it.
9. Giving out information to a third party.
The devastating consequences of divulging patient information to a third party, especially over the phone, have previously been reported in the press and can be disastrous. Unfortunately people can be very deceptive. We never really know who we are talking to and a healthy degree of scepticism may save embarrassment or complaints later. Whilst we all want to help the police in their investigations, this cannot override patient confidentiality. Even acknowledging that a patient is / was seen, is a breach of confidentiality. These breaches can occur despite the best of intentions. Potential traps include
1 Police enquiries following assaults or accidents
2 High profile media cases
3 Relatives wanting to ‘speak privately’.
4 Cold calls and unannounced visits.
5 Patients ‘GP’ or ‘family friend’ calling - clinicians need to be satisfied they are talking to a bona fide person - people can be devious.
6 Leaving messages on a family answer phone.
7 Care is also required when divulging the circumstances of how an injury occurred - Anecdotally the circumstances resulting in the injury may be somewhat suspicious.
Whenever possible clinicians should therefore ask the patient for their consent to speak to third parties, at the earliest opportunity. If it’s an assault or road accident, the police and family may well be calling for information soon.
10. Aftercare
Appropriate follow up and advice should always be offered to patients. Not all patients require a specialist referral or specialist review, but if not, they do need to be given appropriate advice, including what problems they should look out for and when it may be necessary for them to return. All patients with fractures involving one of the sinuses, even if only suspected, (i.e. most facial fractures involving the cheeks and upper jaw) should be advised ‘Don’t blow your nose”. The concern here is that forceful blowing of air (and bacteria from the nose) through the fractures into the soft tissues will result in severe infection. Simple advise, but easily forgotten. Facial lacerations are also another source of dissatisfaction and litigation. Whilst not all need to be treated by a ‘specialist’, aftercare is an important part of the treatment package and has a significant impact on the final cosmetic result. All, but the most trivial of lacerations should be followed up by an ‘appropriately qualified’ clinician - this of course is subject to varying interpretations.
However patients themselves also need to take an active role in their aftercare, as directed by their doctor or specialist. Outcomes are often improved when a patient is highly motivated. Currently the ‘invisible scar’ does not exist, even in the most experienced of hands and patients should therefore never be promised this. Unpredictable factors outwith our control may adversely influence healing. All injured teeth carry an uncertain prognosis and therefore all dental injuries need to be followed up by the patient’s dentist.
Michael can be contacted on: michaelperry@nhs.net
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