Anonymised Medical Negligence Report

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The Web Presence of Donald A. Campbell, Consultant Neurosurgeon serving the Courts in UK, and Ireland, Europe, America, and the Far East since 1984

Mr D. A. Campbell BSc. MB. ChB. FRCS. FRCS(Ed).


Unit 3, Park Hall Farm, Adderley Road, Cheadle, Staffordshire, ST10 2NJ.

Tel/Fax: 01538 757435

Email:  Bellerophon144@me.com


ALLEGED MEDICAL NEGLIGENCE REPORT (ANONYMISED)


The report is addressed to the Court by whom the matter is to be heard


RE:                                                    Mrs B

DATE OF BIRTH:                            12th. Never 2222

SUBJECT OF REPORT:                Alleged Medical negligence

SUBSTANCE OF REPORT:

The report is prepared on the basis of instructions received from instructing solicitors by letter dated 28th June 2005 and by additional written and oral instructions as appended hereto. In preparing the report I have relied upon information provided by the solicitors, as well as the material listed as appended hereto.



This is the first report of Mr D A Campbell











Appendix I

Appendix I

 

 

Mr D A Campbell FRCS (London)  FRCS (Edinburgh)

 

 

Graduate of Edinburgh University Medical School.

 

Full-time NHS Consultant Neurosurgeon for 12 years until 1996 and thereafter remains in active medicolegal practice in Harley Street.

 

Special interest in Cervical and Spinal Surgery, missile injuries to the head and spine, and stereotactic surgery.

 

Involved in postgraduate lecturing to doctors and lawyers involved in medico-legal issues

 

Extensive experience in medico-legal work, having given written or oral evidence in excess of 5000 cases.

 

Trained and experienced with regard to CPR procedures, and has wide experience in compliance with orders of the Court regarding medical evidence in personal injury cases.

 

 Experienced in producing medico-legal reports relating to personal injury claims, being instructed by claimant and defendant representatives, as well as receiving joint instructions.

 

Member of Society of Expert Witnesses

 

Listed in:

 

Expert Witness Directory

UK Register of expert Witnesses

Expert Witness Website

 

G.M.C. Registration                No. 1333231(S)

 

Professional Indemnity Insurance Hiscox Insurance

 

Waiting list approximately eight weeks.  Available for medicolegal consultation at private consulting rooms and hospital in London, Birmingham, Brighton, Derby, Gloucester, Manchester, Newcastle-under-Lyme, Norwich, and Sheffield.






Appendix 2


MATERIAL RELIED UPON


1.i  Instructions received by letter dated [reference:] to examine and prepare a medical report on Mrs [date of birth:], in respect of potential clinical negligence claim

1.ii  Photocopied General Practice records

1.iii  Records from A Hospital

1.iv Records from M Hospital

1.v CD ROM

1.vi  References Relied Upon:


1]  Greenfield’s Neuropathology, Sixth Edition by Graham and Lantos

2] Medical Negligence: Cranium, Spine and Nervous System by Garfield &                  Earle

3]  Northfield’s Surgery of the Central Nervous System, Edited by J D Miller





I have been supplied with documents and investigations in relation to Mrs B, as well as a CD ROM of radiological investigations and hard copies of radiological investigations.  The folders with which I have been supplied include the General Practice records, A*** Hospital records, K*** Hospital records [volumes 1 and 2] and M*** Hospital records [files 1 and 2]. I have also been supplied with cut films of various investigations from M*** Hospital and K*** Hospital.


The CD ROM contains a plain X-ray of Mrs B dated  which is a CT scan.  I would say at the outset that the CT scan available on the CD ROM has been supplied in a format which makes it almost impossible to interpret.  What I can say is that the imaging software will not allow zooming or identification of individual slices and on screen the images are only 45mm x 50mm; it is impossible even to read the names of the individual slices. What I can say is that the images seem to have been stored on some form of microfilm and another patient’s scans are partly visible, but I cannot read the name. There is a label on the image stating that it was taken on  of F B.  All that can be said is that she appears to have an Arnold-Chiari type I malformation [a congenital abnormality with low cerebellar tonsils].  There is lateral ventricular dilatation with ventricular shunts present anteriorly and posteriorly in the right lateral ventricle, an occipital enhancing lesion overlying principally the left side, although the right side of the occiput is involved and there appears to be an infarction of the occipital lobe [old] affecting the left occipital cortex.  The third ventricle is enlarged but the cerebral sulci at the top of the brain appear to be intact.  The image is frankly uninterpretable.


1. HISTORY of PRESENT CONDITION


1.1 The history as supplied to me in the form of a letter of instruction is that Mrs B was aware of ‘flu-like symptoms on  and began  to vomit and to complain  of a headache.  By  her headache had gone and she had ceased vomiting.  On  her symptoms returned and Mrs B’s husband telephoned NHS Direct who apparently advised that she might have ‘flu.  Mr B then took his wife to her own General Practitioner, who prescribed migraine tablets.  Because of persisting vomiting an emergency Doctor on Call was summoned around 3.30pm who arranged for an ambulance to take Mrs B to M*** Hospital, where she was admitted.


1.2  A CT scan was undertaken on the following morning.  The CT scan resulted in the diagnosis of a pineal tumour and Mrs B*** was transferred to K*** Hospital for further management.  I understand that whilst still in M Hospital she suffered several fits.  There appears to have been a delay in her transfer for about eight hours to K *** Hospital, and she was taken as an emergency to theatre on th l 200 where a drain was inserted, and I understand that a further drainage procedure had to be undertaken. She was then taken via the Intensive Care Unit to the High Dependency Unit under the care of Mr X.  She subsequently developed MRSA infection but this was treated.  Her hydrocephalus was dealt with by an endoscopic ventriculostomy because she was felt not to be well enough for surgery.  She was subsequently transferred back to M*** Hospital with the intention that she should be reviewed by the Neurosurgical Unit every six to eight weeks and to have MRI scans prior to each review.  I understand that Mr X advised that the operation would be too complex and she should be managed conservatively i.e. that nothing should be done.


1.3 Mrs B’s condition apparently continued to deteriorate and by , following review, a shunt was inserted to treat the hydrocephalus.  I understand by  it had been realised that no shunt had, in fact, been fitted in  or , although there seems to have been some suggestion that there had been. Because of concern about management she was transferred to the care of at A*** Hospital for a second opinion and by 20 the tumour was removed. She was transferred back to M*** Hospital prior to her discharge in 20.  She subsequently underwent rehabilitation at S*** Hospital and I understand from the letter of those instructing me that no radiotherapy has been given or suggested at any time.


2. REVIEW OF THE SUPPLIED RECORDS


2.1 General Practice records:

These are present in Lloyd George card format between 1964 and 2004, and in computer-generated format up to  2004.  Prior to the events to which my report refers Mrs B appears to have undergone a partial removal of in 1988 for. She was involved in a road traffic accident in 19 when a car she was travelling in rolled over, but there is no major injury recorded following this.


2.2 In   she was noted to be vomiting following a holiday in Turkey and no abnormality was found on examination of her abdomen.  In 20 she developed gynaecological problems and was noted to have “Neck pain and stiffness in the mornings”.  She was referred to the Gynaecological Clinic in  20 and the next entry in the notes is 7th [I cannot read the year but which is probably 20] which suggests that she was getting visual disturbance which seems to have been put down to painkillers.  The next handwritten entry seems to be on  20 which simply says “migraine” and she was given Zomeg, a drug to treat migraine.  On  20 it is noted that there was a visit and she was in K*** Hospital with “tumour in the brain”.  A note of 20 records “Spoke to partner now says that [illegible] much better now and a visit is not needed - I suggest he rings back if any deterioration observed - he agreed with this plan.”

The computer-generated notes overlap the Lloyd George cards to some extent, but we have consultation records from 1998 to 20.  These note on 20 that she had had vomiting +++ associated with severe headache and chest pain. She was given an injection on a home visit that day, an anti-emetic, and it was then noted that on 20 that she was getting double vision, occasional neck pain and the examination section notes that this was true partial VI nerve palsy [although it does not actually say that] in other words, it was not hysterical.  Thyroid tests seem to have been done in 20 which were normal and it was noted on 20 that she was complaining of abdominal problems, particularly gynaecological, and she was given tranexamic acid.  This seems to be the end of the consultation with that General Practitioner and it was noted that she was moving to a new Practice, presumably the one who kept the Lloyd George handwritten notes.


2.3 Attached hospital correspondence, prior to events to which my report refers occurred, includes some laboratory results - these are marginally out of the normal range, but I do not think that there is anything specific in them that would raise any queries.  There is confirmation that she had a removed in 19 and it was noted that this should be removed because none of the investigations could exclude a tumour. No evidence of malignancy was seen in the formal histology after the operation.  A minor injury is noted in a solicitor’s letter in 19 when she injured her foot. A new patient registration document in  20 essentially noted no significant illnesses and she was referred to the Gynaecological Clinic following an ultrasound in 20.  The first document of relevance is a Doctor on Call letter dated 20 which contains the comment “Thanks for seeing Miss YYYY [her maiden name] who may just have migraine but I am concerned there may be more to it.  She has had a headache since Tuesday [query right-sided] and vomiting.  She has had difficulty in walking today and has generally brisk reflexes with bilateral upgoing plantars”.  That letter is dated 20, timed at 1735 hours.  There is another document timed at  hours on 20 noting that she had been vomiting and had seen her own General Practitioner who had prescribed migraine [sic] “Collapsed in a heap on bathroom floor”.  Presumably this is the document that caused the consultation at  hours.


2.4  There are then some documents from K*** Hospital. Among the most relevant of these is a discharge summary of 20 from K*** Hospital noting a lesion - histology uncertain, hydrocephalus and MRSA.  It was noted that she had seizures, was treated with anti-convulsants and a drain.  It was noted that tumour markers had not suggested malignancy, although this was a clear risk, and it was noted that Mr X was “unkeen to carry out a biopsy on the pineal lesion as the patient’s clinical condition was not well enough”.  It was clear that it was intended to review her after six to eight weeks to see if she was well enough to have a biopsy.  On 20 it was noted she had two months’ rehabilitation and it was decided to repeat an MRI scan after four to six weeks to see if there was any change and it was noted “I would not be keen to carry out any definite surgery until we felt she had neurologically plateaued”.  There is then a discharge summary from A** Hospital dated 20 - this has been written by a clinical nurse practitioner and I will comment on this in more detail when I review the A** Hospital notes.


2.5 There are Occupational Therapy notes from M** Hospital following her surgery. There is then correspondence from the Gynaecology Department essentially stating that they did not think her gynaecological problems were arising from the uterus and in 20 it was noted she had been admitted with a suspected pulmonary embolus.  


2.6 She seems to have been reviewed in March by Mr Z Consultant Neurosurgeon at A***  Hospital, who noted significant residual problems and, in fact, asked for an MRI scan to be carried out to assess the degree of resection of her.  She was then referred to the Ophthalmic Clinic at A*** Hospital by the local M***  Ophthalmologist.


3. Review of A***  Hospital notes


3.1 I have been supplied with records from A***  Hospital which include nursing records and medical notes.  I note as a matter of surprise, given that A*** is a university hospital, that the Neuroscience’s “Nursing assessment” is printed with glaring grammatical errors in the nursing documents.  There are also Occupational Therapy notes and physiotherapy notes.  There are, however, useful medical notes as well as correspondence sheets.  The records note that Mrs B  was referred from K*** Hospital for a second opinion at the request of Mrs B’s   husband.  A typewritten letter to at A*** Hospital dated 20 notes that Mrs B had presented at M*** Hospital with what was described as “coma inducing hydrocephalus”.  I may be unnecessarily critical, but given that K*** Hospital is an academic unit and a referral has been made to A*** Hospital, one of the most respected academic units in Britain, the correct phrase should be “admitted to M with hydrocephalus of sufficient severity to result in a coma” - the coma does not cause the hydrocephalus.  Essentially, the letter states that hydrocephalus was diagnosed in 20, a CT scan had shown a mass with hydrocephalus, an external ventricular drain was inserted which was complicated by MRSA infection.  Once this was carried out an endoscopic third ventriculostomy was carried out from which she appeared to make a good recovery.  This is a procedure in which the front end of the third ventricle is opened to allow cerebrospinal fluid to escape and treat the hydrocephalus.  I would have to say from my review of the scans that I do not believe it was effective and the major problem with endoscopic ventriculostomy is that it may well close off spontaneously.  She was then reviewed with a CT scan in 20 and the letter contains the comment “which showed that the ventricles are still dilated, and we also performed a ventricular tap through her reservoir which demonstrated pressures of 30cm”.  This ought to state 30cm of water which shows that the intracranial pressure was significantly raised - in other words if the third ventriculostomy had worked at any time it certainly was not working at that point.  The note was then made that a shunt was to be inserted.  Given that no histological diagnosis had been made, and no radiotherapy had been given, this seems quite an eccentric approach to the presence of a **** tumour known to be present on scanning in a  year-old woman.  It is then noted on discussion with the neuroradiologists that it was felt that this was likely to be calcified *** - I will comment later on the likely nature of tumours in the ** region quoting from Greenfield’s Neuropathology - again, this seems a somewhat eccentric diagnosis to make.  The letter then goes on to suggest that K***  Hospital had suggested a biopsy or re-section depending on the operative appearance, but that Mr B wished to have a second opinion.


3.2 There is a handwritten letter from Mr B with someone else’s handwriting at the top saying “What is this about?” which I presume is a request from Mr B to ZZZ.  Of even more concern is a note from ZZZ’s secretary noting that Mr Y said that he had “never looked after a patient with a pineal tumour before”.  A further copy of the letter has some handwritten addenda to it which appear to be signed by a Neurosurgery Senior House Officer No. 4666 noting that since 13th October 2003 Mrs B had remained confused and was getting episodes of increased drowsiness.


3.3 A referral letter to Mr C from Dr T,  Consultant at M Hospital, dated  notes that Miss K had not improved and that the family felt that no clear way forward with her management had been undertaken.  I find this letter very concerning - Dr T is clearly worried about was has happened and  ends his letter by saying “It would be a great help to have confirmation that my understanding of your plans is correct and to learn when you plan to review her”.  This should be totally unacceptable management in British Medical Practice - the most important factor when transferring patients between hospitals is that there is clear, unequivocal communication between consultants and that consultants should feel able to pick up the telephone and discuss matters directly rather than having to send sad letters like this. 


3.4 A letter dated  sent from a Senior House Officer to Dr T  [I have to say that this is frankly unacceptable practice - if only as a matter of pure courtesy one consultant should write to another] notes that  “We had hoped that Mrs B would be in a situation to understand the proposed courses of action”.  Quite frankly, it is manifestly obvious that a clear course of action was  not present and this seems to imply that it was Mrs B’s fault that a clear explanation had not been given to her - if that is the case then General Medical Council’s recommendations on good  medical practice are that one must make certain that either the patient or their relatives understand clearly what is being proposed; this manifestly has not been done.


3.5 The admission notes to the Critical Care Unit dated  seem to suggest that Mrs B was operated on on the day of arrival or very soon after - it was noted that history was as set out in my review of the General Practice notes and the instruction letter and that a resection was undertaken by a sub-occipital craniotomy.  Post-operative care is recorded in the Critical Care Unit notes on a daily basis and she appears to have been transferred to a High Dependency Unit on at which point she was noted to be alert, fully conscious and comprehending well, although she was occasionally disorientated.  Post-operatively she appears to have continued well and the histology is recorded in a typewritten report [undated] under hospital number  as “a very cellular tumour which on paraffin section proved to be a XXXXX with no mitosis”.  Nevertheless, the tumour is said to be quite active.  


3.6 The handwritten operation notes show Mr K to have been the operating surgeon on .  There is a handwritten sketch and a standard approach has been used under microscopy which under a frozen section showed a cellular tumour with a total macroscopic excision being recorded.  The operation note is clearly written and of high quality with a standard post-operative management.  


3.7 I do not wish to burden the Court with excessive review of details such as what Mrs B had for breakfast on a day-by-day basis but would simply say that the nursing records record a gradual improvement, although there was a delay in transferring her back to M Hospital because of a shortage of beds.  She was noted by the physiotherapists and the occupational therapists to require assistance with feeding.


4. Review of M Hospital records


4.1 The admission notes on  to M Hospital were, in fact, supplied in the middle of K Hospital notes between pages 47 and 67 of the supplied bundle.  The records show that on 19th April 2003 Mrs B [actually referred to as Miss K] was admitted with a four-day history of headache and vomiting with pain going into the occipital region unrelieved with painkillers.  It was noted she had been sleepy and drowsy and was unsteady on her feet.  It is also noted that her husband gave a history of abnormal behaviour in the preceding period, although it is not said what this means, whether this means that she was unsteady or whether she was psychologically unusual or blacking out.  It is also noted that she was having what appear to be seizures or “absences” lasting for a few seconds in association with an unsteady gait.  It is noted that she had been incontinent of urine that day and was having gynaecological problems.  Clinical examination states that there was no abnormality on examination of the cranial nerves - this simply cannot be true.  She was noted to be sleepy but rouseable.  Her heart rate was 60 per minute and her blood pressure was 106/64.  I have records in other places from K*** Hospital noting that her normal blood pressure seemed to run around 120/80.  I would interpret this admission blood pressure and heart rate as being evidence of seriously raised intracranial pressure, the so-called Cushing reflex, in which there is a slowing of heart rate and initially a dropping of blood pressure which subsequently reverts to a rising blood pressure and an even slower heart rate which can lead to cardiac arrest.  Reflexes were said to be brisk bilaterally and the plantar responses are initially shown as being extensor but then the extensor arrow is crossed out and flexor is noted.  Given that the General Practitioner saw that there were bilateral extensor plantars I do not believe that the plantars could possibly have been flexor on admission.  It is also noted that fundoscopy was normal - again, this simply cannot be true.  Be that as it may, the admitting doctor decided that there might be some sort of space-occupying lesion in the head and undertook various investigations and arranged for a CT scan of the head to be undertaken.


4.2 By 2350 hours on 19th April 2003 [Mrs B was admitted earlier in the day, but the time is not recorded] it was noted that her right pupil was fixed, that she had equivocal left plantar response but a flexor right plantar [I do not believe this either], that there was weakness and they seemed to question whether she was suffering from meningitis.  It would appear that by this stage they had decided they were not going to do a CT scan.  By 0730 hours she appears to have quite clearly had a fit.  Her blood pressure now had risen to 125/60, but her pulse was still 60.  This doctor said “I think she needs a CT”.  This is certainly the case and it should have been done on admission.



4.3 On 20th April 2003 a ward round with Dr Hussain was undertaken. I have to say at the outset that this contains at the end of the letter “Plan.  1] urgent CT scan and lumbar puncture” - this is a schoolboy howler mistake which is completely indefensible.  Under no circumstances should anyone ever perform a lumbar puncture on anyone suspected to having an intracranial tumour - it has a high chance of killing the patient.  Even to suggest it is a matter of serious professional misconduct and shows a serious lack of understanding of neuropathology.  This comment is not made on the basis of being a specialist neurosurgeon - it is a matter on which the medical student would quite correctly be failed immediately if this suggestion was made.  


4.4 There is what appears to be a nursing evaluation report at 0600 hours on 20th April 2003 noting that all medication should be given rectally because she was unable to keep anything down.  


4.5 Pages 56 to 62 are duplicates of the earlier pages.  Page 63 refers to a CT scan of the head showing that there was a mass in the brain with marked dilation of the ventricle, including the third ventricle and the inexplicable comment is that this is “in favour of a meningioma” - this is simply not true.  However, I would not criticise a peripheral hospital radiologist for making this statement, but it would appear that K Hospital appears to have taken this at face value.  It is then noted that Mrs B’s husband was told that there was a brain tumour and it was not clear whether it was benign or malignant and would need a biopsy.  This comment was made by a junior member of a medical ward.  This statement is absolutely correct and I find it even more odd that K Hospital did not undertake biopsy.  There then seems to have been another entry in which a Dr S, Specialist Registrar, was called because Mrs B had collapsed.  The notes then go on to suggest that this is a fit and that they discussed the case with a Specialist Registrar at K Hospital, who would look at the scans and call back.  It is noted that if the patient continued to fit she was to have a phenytoin infusion with caution because of the risk of bradycardia [slow pulse rate] and would need reviewing.  Again, this is quite inexplicable.  If someone is fitting phenytoin takes up to seventy-two hours to begin to work effectively.  Bradycardia is not a problem with phenytoin so long as it is given by infusion, but if someone is fitting like this the correct treatment is to give dexamethasone, a steroid to reduce the effects of the tumour and a fast-acting anti-convulsant such as diazepam, watching the patient’s respiration.  I am not sure whether this advice to give phenytoin was given by K Hospital.  By 1530 hours it was noted that the patient should be intubated and ventilated for transfer - this is absolutely reasonable. There then seems to be a note by someone whose signature I cannot read, but it finishes “334 anaesthetic ...[something]” noting that the inpatient was intubated for transfer.  The next set of notes on page 67 appears to be the admission note at 1945 hours at K Hospital.  This would seem to suggest that at most four hours has elapsed.


4.6 On reviewing the Microsoft Autoroute this journey would take approximately fifty minutes; if we are being generous, let us say and hour and a half to allow for traffic, even with a police escort.  This would suggest that it has taken approximately three hours to get the patient intubated between the decision being made at 1530 hours and the patient arriving after an hour and a half journey at K Hospital.  There is no record in the notes of why it took so long.  The K Hospital notes seem to suggest that an anaesthetic Specialist Registrar recorded the erroneous diagnosis from M Hospital and it may simply be that which has led to a feeling that this could be a meningioma.  


4.7 On 21st April 2003 it would appear that a repeat scan was undertaken and it is noted that the external ventricular drain fell out during this - practical experience is that unfortunately this is not an unusual occurrence!  On 23rd April 2003 it is noted that Mr B was “Aware of current situation and waiting for Frances to wake up”.  I find this really quite inexplicable.  The patient should have woken rapidly after the insertion of an external ventricular drain because it is the hydrocephalus which results in the reduced conscious level.  By 7th May 2003 it is noted that she was to have a ventriculostomy [I have to say that I can hardly read any of the signatures or entries in the notes, although they have bleep numbers against some of them].  On  someone who is described as a D/C Co-ordinator - I have no idea what this means perhaps Discharge Coordinator - notes that there is some confusion about the long-term plans and at the end says “Please could medics document the plans”.  In other words Mrs B was still in Intensive Care and no-one seems to have had a clear idea where the treatment was going or what was to be done.  On it is noted that there was a problem with the tracheotomy and that the blue dye test had been failed.  There is a large amount of irrelevant verbiage in the notes due to the present fashion for allowing anyone and everyone to write whatever they want in medical notes and the only result of this is to give a false sense of importance to some relatively minor notes and also to result in significant confusion in the planning and monitoring of the medical progress of patients.  This case is an outstanding example of this - the notes are confused, it is impossible to get an adequate medical review of the patient’s progress or otherwise, and in my view this is one of the causes for the lack of clarity in planning what is to be done with the patient.  In  it is noted that the results of the cerebrospinal fluid specimen were discussed with Dr A-S.  I have to say with some sadness that I cannot see evidence of any medical staff making any entries in the notes between 11th June and 27th June 2003, although there are plenty of notes from Speech and Language Therapists and Dieticians.  Similarly, between 30th June and 30th September 2003 there are no medical notes - if medical notes were kept in a logical sequence this serious deficiency in note-taking would be immediately obvious to the medical staff.  There then seems to be a gap and the patient is re-admitted on 30th September 2003.  A further example of the appalling lack of care being suggested is the admission note “Plan.  Pre-operative bloods.  Nil by mouth from midnight.  Re-examine if patient becomes unresponsive”.  If the patient became unresponsive they do not require re-examining, they need emergency treatment.  The same handwriting continues to state that the cranial nerves II to XII were grossly normal - this lady has a shunt in place, a pineal tumour, difficulty with eye co-ordination and papilloedema.  It is simply impossible  for her to have normal cranial nerve examination.  It is unfortunate that although they have recorded that there was to be a ventricular peritoneal shunt to be done in theatre on the following day the subsequent notes on  have not actually recorded what operation was undertaken. 



4.8 At least on this occasion it would appear that almost daily notes have been kept by the medical staff sequentially.  As a matter of interest, given my earlier remark about the Cushing reflex, we can see that on 11th October 2003 her pulse rate is recorded as 86 beats per minute.  On 13th October 2003 is noted that Mr B was expressing his concern that Mrs B had not improved following shunting.


4.9 We then have a large amount of irrelevant entries from Speech and Language and Occupational Therapy - I note the occupational therapist felt that a neuropsychology assessment would be required to determine Mrs B’s rehabilitation potential - the matter that would determine a rehabilitation outlook would be how rapidly her tumour was treated.  A ventriculo-peritoneal operation is recorded on 3rd October 2003 and it would appear that Mr C inserted this.  I have to say that I note that there was clear cerebrospinal fluid under “moderate pressure”.  It does not appear that any record was made of what the pressure was.  On  it was noted that the Senior House Officer was asked to measure the pressure of the shunt by Mr B Registrar to Mr C.  


4.10 The last entry in the notes that I have is dated 27th October 2003 when it is noted that Mrs B was going to be transferred to A Hospital.


4.11 There are then various investigations recorded including nursing records from the various admissions which take up several hundred pages but contain very little useful information. There is a large amount of unnecessarily complicated, pseudo-scientific entries in the notes.  For example, page 413 contains the phrase “communication towards the end of sessions uttered five meaningful syntactically intact propositional sentences in a low, audible, vocal volume”; in other words she said five words quietly. I have looked through the records in an attempt to see what drugs have been prescribed during her time in hospital.  Of particular interest is the period following her first admission at K Hospital.


4.12 There are two pages [pages 17 and 18] in the K Hospital notes consisting of a form with a protocol to decide whether or not to resuscitate a patient.  None of the records make any mention whether or not dexamethasone, an absolutely essential treatment for someone with an intracranial tumour, has been given. On the original admission to M Hospital a plan noted that she was to have painkillers [remember the nurses said she was unable to tolerate anything by mouth and had to give them rectally] and she was given phenytoin, a less than ideal anti-epileptic medication.  There is no mention of her ever being given dexamethasone.  The K Hospital notes record that she is to be nursed at 30 degrees head-up - this is a complete waste of time, and is an old wives’ tale which was shown by myself and Dr Tesementzis in 1972 to have absolutely no beneficial effects at all  and to have a positive disadvantage in that it made it more difficult for the nurses to look after the patients’ pressure areas.  I can find no prescription chart for this admission at all, and certainly the prescription charts for  contain no evidence of any steroids being given. 


4.13 I should say at the outset that some of the A Hospital records in fact contain about fifty pages of M Hospital’s records.


4.14 The M Hospitalrecords appear to have been paginated.  The records also appear to be in a somewhat unusual order, but I shall do my best to try to provide a sequential listing of events in time order.


4.15 Volume 2 [pages 386 to 493] contain a large amount of paperwork from Speech Therapy and Physiotherapy as well as nursing notes.  There are also various fluid balance charts and drug prescription charts which are some of the notes which are mixed up with K Hospital notes.  For example, on page 461 we have a handwritten operation note from 6th May 2003 in which it would appear that Mr B, another Consultant Neurosurgeon at K Hospital, appears to have operated with Mr C in order to do a third ventriculostomy and insertion of an Ommaya reservoir.  Inexplicably this note is inserted inside K Hospital nursing notes for, pages 423 to 426; page 427 relates to .  Page 428 relates to  - I will not go on listing the inconsistencies, but I have to ask why, in view of the fact that there are such serious issues here, that these notes have not been appropriately sorted in time and date order.  I think a section of the K Hospital notes should, however, be drawn to the attention of the Court, best illustrated by pages 456 and 457 in relation to the question of the patient’s ability to comprehend and retain information and the involvement of the family in obtaining consent.  All the boxes appear to have been ticked without anyone actually reading what these documents mean and taking cognisance of what they require.


4.16 In any case, it would appear that a third ventriculostomy was undertaken and an Ommaya reservoir was inserted.  I cannot read the signature, but the only reason why two consultants would be required in my experience is that one of the consultants would require further training and was not felt to be able to operate on his own - perhaps Mr C was appointed on the understanding that with any procedure which he had not previously seen or in which he had not been trained he would ask for the assistance of another consultant.  I know Mr B and he is most certainly capable of undertaking this type of surgery.  There is correspondence in the A Hospital notes which suggests that Mr C admitted that he had never seen a pineal tumour before would perhaps support my view of things.


4.17 On 21st April 2003 it would appear that an external ventricular drain was re- 

inserted but there is no mention whether or not an Omaya reservoir was removed.  


4.18 The M Hospital records contain notes referring to rehabilitation but interspersed with them on page 452 we have a fax cover sheet from K Hospital relating to page 453 and which seems to be a physiotherapy discharge summary.  Even this document concerns me, because under “Problems on assessment” it notes “1] Trache in situ - problems weaning - failed blue dye test”.  This means that where blue dye was inserted in the patient’s stomach it re-appeared through the tracheostomy, in other words the patient was incapable of maintaining their normal swallowing reflexes.  If that is the case this needs to be investigated even more.  I am also somewhat puzzled by the fact that we now have a third consultant, Mr S listed as the consultant looking after Mrs B on 29th July 2003.  There is a planning meeting record on pages 412 to 414 which I presume has been undertaken at M Hospital, but these are then followed by speech and language therapy reports from K Hospital on pages 415 and 416!  


4.19 Volume 1 of the M Hospital records contains a mixture of notes from K Hospital and A Hospital and is also in a somewhat eccentric date order; for example, page 1 is an admission/discharge summary for  to  for the Geriatric Unit for Mrs B.  Page 2 is a Outpatient Clinic note for , page 3 is an assessment admission for  and various Outpatient letters up to page 15 which is then As Hospital discharge summary notes for .  Page 19 is a K Hospital discharge summary for .  Page 36 is a letter from Outpatients in March 2004 from Mr K at A Hospital.  Page 51 is another letter dated from A.  Page 129, however, is from  when Mrs B appears to have  been transferred from K Hospital for rehabilitation.  These go up to page 136 when on page 137 we have a  gynaecology note before reverting back to 3 on page 140.  Page 163 relates to the period between  and .  Page 173 relates to  and page 174 relates to  and is a gynaecology note in the middle of rehabilitation notes.  There is then a series of laboratory results.   There are evaluation reports but it is unclear whether these come from K Hospital or M Hospital, but relate to December 2003. 


5. Review of K Hospital records


5.1 Volume 1 contains correspondence and some radiology reports.  In  there is a note from M Hospital to Mr C at K Hospital noting that Miss K had been transferred back to M Hospital following “her third ventriculostomy for hydrocephalus secondary to a pineal tumour”.  The letter from Dr T, Consultant Physician, goes on to state “My understanding is that your plan has been to give her a period of recovery and rehabilitation prior to reviewing her for a definitive decision on further management.  The suggestion was that you would review her after about six weeks”.  I have already referred to this letter in my review of the M Hospital notes.  


5.2 On page 13 of the notes there is a record “She was confirmed to have a pineal tumour, removal of which was felt to be too complex and she was therefore managed conservatively”.  I have to say that although this letter is written by an occupational therapist it was copied to Mr C the Consultant Neurosurgeon.  I find this statement quite incredible.  


5.3 There are two cytology reports which I presume relate either to cerebrospinal fluid taken at the time of the third ventriculostomy or from the Ommaya reservoir.  Essentially, Dr A, Neuropathologist, could not find any malignant tumour nor any malignant tissue and Dr B felt that his specimen was not diagnostic.Pages 21 to 23 are a letter from Mr C to Dr B, Clinical Director of Neurosciences.  This refers to a letter in capitals which seems to be a letter of complaint from Mr B but which I have not seen in the records.


5.4 The second paragraph contains somewhat florid language which certainly is not, in my view, an appropriate manner in which to respond to what appears to be a complaint about clinical management. To suggest that someone is “virtually at death’s door” and then say “subsequent to a ventriculostomy being placed” [ventriculostomies are not “placed”, they are made] and then furthermore say “I was astonished at the extend [sic] at which she recovered and delighted but she did make a recovery”.  This is incomprehensible.  I cannot understand the next sentence either “We did place a shunt after the infected external ventricular drain had been treated”.  You do not “treat” ventricular drains - an infection may be treated.  I am concerned to see that Mr C notes that he had never seen a pineal tumour - to make the comment that these tumours are a small part of the surgical repertoire is no excuse - if one does not feel competent to handle something like this one is under an ethical duty in British medical practice to ask someone who is able to deal with it - you do not simply say that you are going to “treat something conservatively”.  Going on to suggest that there are “senior consultants” who have “long experience” is a peculiar choice of words - a consultant is a consultant, there are neither senior or junior consultants. To go on to suggest that Professor P “did not have huge experience in this area” is quite incredible - I know  P, who is a very careful, ethical and highly experienced surgeon.  On page 2 the statement that “Dr K is a junior consultant” again seems to imply there are different grades of consultant - this is simply not true. If it were true, however, this seems to imply that even a relatively junior and inexperienced consultant is able to carry out surgery which Mr C does not feel capable of doing.  He then seems to go on to contradict himself by suggesting that tumours are rare, that within K “we have vast experience with them” and then goes on to say “one does not have to be qualified to deal with pineal tumours”. He then goes on to say that he has not seen any pontine tumours.  I must say that I am rather surprised that a hospital of the reputation of K Hospital feels happy to appoint a consultant neurosurgeon who has never seen or performed surgery on pineal tumours on or pontine gliomas.  I would point out that pontine gliomas are, in fact, far more common than pineal tumours.  Both of these tumours, however, do require an experience in stereotaxy.  A letter dated  from Mr C to Dr B begins in a way that is quite inexplicable - in a matter as serious as this simply to dash off a letter which one does not even sign on the basis of memory without reading the notes is really not acceptable practice.  I think the comment in paragraph 3 of this letter is really quite offensive - in my experience patients who get married in these circumstances usually do so because they think they are going to die, not because they are “well enough to get married”.


5.5 There is a letter dated  from Dr B in which it is suggested that it would appear that Mr C has not even bothered to reply to the complaint letter.  Pages 27 and 28 contain the referral letter to Professor P - I must say I find the addressing of this letter somewhat eccentric as well - if the letter is addressed to Professor P there is no need to repeat the fact that he is a professor in the second line of the address.  Further letters then repeat the suggestion of September 2003 “further rehabilitation should be undertaken before considering further management of Mrs B”.


5.6 Pages 37 to 39 contain further comments suggesting that “Tumour markers did not demonstrate any abnormality suggestive of a germ cell tumour, although this would also be high up on the diagnosis list”. These are the two cytology reports that I have seen. One is not diagnostic and the other simply says no malignant cells were seen - this means hardly anything.  A further letter on page 42 I think may explain the suggestion in one of the letters that there had been three ventriculostomies - I think it may simply be that the person writing the letter did not understand the difference between a ventriculostomy of third ventricle and a third procedure.


5.7 Pages 47 to 66 consist of the admission notes to M Hospital.  I have already commented on these earlier.


6. REVIEW of SUPPLIED RADIOLOGY:


6.1 Review of the supplied radiology shows a chest X-ray from A Hospital x 3 with some slight “fluffiness” of the lung fields suggestive of some mild chest infections.  There is a plain X-ray of the skull from A Hospital dated which clearly shows post-operative film with some air within the head and skin clips in position.  I can see an occipital cannula and a reservoir as well as a ventricular peritoneal shunt from the occipital cannula.  The film is not well-centred so it is impossible to comment on this as to the appearance of the clinoid processes.  There is an abdominal film showing her to be somewhat constipated with the peritoneal end of a ventriculo-peritoneal shunt in situ.  


6.2 There is a pre-operative MRI scan  from A Hospital dated  showing the tumour in the posterior part of the third ventricle in the region of the pineal.  It also shows somewhat dilated lateral ventricles and third ventricle with no evidence of acute hydrocephalus, and the brain is generally atrophic, which I would put as being secondary to the chronically raised intra-cranial pressure.  The tumour is seen to have been almost completely removed and there are some post-operative changes on the left side of the third ventricle.  There is a CT scan also from A Hospital dated 10th November 2003 which shows a considerable quantity of air within the head, particularly in the anterior horns of the lateral ventricle but no residual tumour is seen.



6.3 There are radiological investigations from K Hospital, which appear to be CT scans and MRI scans.  These have initially been supplied in a fashion which makes it impossible to read the information printed on them.    Nevertheless, the abnormalities are so gross that if we can confirm these films do, indeed, belong to Mrs B we can see that there is a massive pineal region tumour [I am unable to comment on the dates or times or even which hospital this was, as I cannot read the films] with calcification on the left side of the tumour.  In some of the films there is the presence of what appears to be the right frontal drain - possibly the Ommaya reservoir which has failed to compress the ventricle.  There appears to be an enhanced scan in which a right frontal ventricular drainage tube has been passed right through the septum pellucidum and goes between the left and right horns of the lateral ventricles - this can occasionally occur, particularly in inexperienced hands - if this were my patient I would actually re-position this and convert it into an external drain.   


6.4 There is an MRI scan supplied on which I can make out the words “F K” but cannot clearly make out the date, time or source - this shows a tumour in the region of the third ventricle extending into the right inferior surface of the lateral ventricle, and there is uncontrolled hydrocephalus with ballooning of the third ventricle.  A further enhanced CT scan shows even more marked hydrocephalus without the presence of a drain in situ. 


6.5 I have subsequently been supplied with Cut Film Copies and my review of these is as follows:


6.6 For completeness I would also confirm that there are various other X-rays present, including chest X-rays of the  Chest, as well as ultrasounds of the pelvis and neck dated .  There is a poor quality single view of the left shoulder dated , which does not show any evidence of fracture, but does suggest to me, osteoporosis.


6.7 Review of M Hospital CT Scans

The first scan is taken on  and shows acute biventricular hydrocephalus and third ventricle hydrocephalus caused by a pineal region mass with calcification posteriorly and on the right. The higher cuts  of the scan show the mass extending more to the right than the left. There is then a scan after injection of contrast which shows the mass to enhance markedly.  The appearances are classical for a malignant tumour in the pineal region. Even with hindsight I cannot see any suggestion of a developing occipital cortex infarct. The scans have been supplied twice i.e.  there are duplicate films of both scans.




6.8 Review of K HospitalScans

There is a CT Scan of  shows that a ventricular drain has been inserted and there is a small bubble of air in the right frontal horn. The third ventricle has collapsed to a more normal size; the fourth ventricle is now visible with normal posterior fossa contents but the lateral ventricles though much smaller are still enlarged symmetrically. I do not believe, even with hindsight, there is any  suggestion of a developing infarct of the occipital cortex at this point.


6.9 A further CT Scan of  confirms the persistence of the tumour, but the lateral ventricles are normal in size and the drain is seen crossing the Septum Pellucidum into the head of the Caudate nucleus and brain substance on the left. This looks like a new drain as the earlier scan showed the ventricular drain much higher up in the brain and not crossing the midline. On the enhanced scan a large draining vein is seen posteriorly on the left. There is undoubtedly a developing infarct of the occipital cortex on the left on this scan.


6.10 A further CT Scan of  shows what may be the same drain but now the ventricular drain is not working so well and the lateral ventricles are enlarging, the third ventricle is larger  but the fourth ventricle and posterior fossa look normal. 


6.11 The next CT Scan is dated  and shows a new drain in situ with a chronic right frontal subdural haematoma, the lateral ventricles slightly better drained and what looks like a chamber in a right frontal burr hole. The tumour is still seen.


6.12 The next scan is dated , and shows the same drainage system in situ, but the lateral and third ventricles are larger suggesting this drain is no longer functioning.


6.13 The next scan is dated  and shows  a repositioned right frontal drain, but this still does not seem to be draining properly as the lateral and third ventricles are still oversize, but the forth ventricle and posterior fossa are normal. The previously noted subdural collection has disappeared, again suggesting the lateral ventricles are under some pressure and not draining.


6.14 There is then an MRI Scan dated  showing a right frontal ventricular drain going into the Septum Pellucidum, the tumour still present though the vasculature  is  much better seen as an MRI is better at showing these. A thin subdural collection is seen over the right frontal area. The lateral T1 images are slightly degraded by movement. The pineal region tumour remains easily visible, and a left occipital cortex infarct appears to be easily seen.



6.15 The next scan is October 1st. 2003 and is a CT Scan taken at King’s, and shows a well developed infarct of the left occipital cortex, what appears to be the same drain still not functioning properly with enlargement of the lateral and third ventricles, and the tumour still present.


6.16 Further M Hospital Scan

I have reviewed a CT scan dated , which shows an occipital subdural collection, dilated third and lateral ventricles and periventricular lucency in the occipital horns of both lateral ventricles, as well as showing two shunts in situ.  These appearances to me certainly suggest that there is raised intracranial pressure on top of significant atrophy (wastage) of the brain and the tumour has been removed apparently completely.


7. REFERENCES


7.1 I think the best way of dealing with this case as a whole is to quote from a neuropathology textbook and a textbook of neurological surgery and then I will set out what should have been done with some attempt at giving an idea of what the likely outcome would have been.  


7.2 The references I wish to quote are Greenfield’s Neuropathology, Sixth Edition by Graham and Lantos, Medical Negligence: The Cranium, Spine and Nervous System by Garfield and Earle and Northfield’s Surgery of the Central Nervous System, Edited by J D Miller.


7.3 The first reference is from Greenfield’s Neuropathology, pages 678 to 679. These define pineal tumours of which pineal cystomas comprise 7 to 30% of all pineal tumours.  They occur more commonly in adults than in children and the median age of presentation is 36 years with a range of 11 to 78 years.  The description of this is “usually CT imaging demonstrates an iso-dense matter with variable calcification contrasted in enhancement that may displace remnants of the pineal gland”.  This is exactly what I can see on the CT scans supplied, although, as mentioned above, these are so unclear I cannot say that I can read the name of the patient on them.  The entry goes on to say “The tumours are typically well-delineated from adjacent structures without evidence of infiltration” i.e. they do not grow into surrounding structures and are therefore relatively technically easy to remove from their site.


7.4 Tumours of the pineal region form approximately 1% of all brain tumours [Greenfield, page 677].



7.5 Meningiomas in the pineal region are rare. They tend to occur in children [31% of meningiomas in the pineal region occur in children] and when they do occur in adults they tend to occur in a younger age group [median age 28 years] and they tend to occur in males and much more commonly a ratio of 2.3 to 1 with a mean age of around 46 years in males. From this it can be seen that the tumour, purely on the basis of the patient’s age and sex and its appearance on CT scan, was unlikely to be a meningioma and much more likely to be a pineal cytoma.  Technically, it is likely that such tumours are easily removable.


7.6 I now turn to Northfield’s Surgery of the Central Nervous System, page 234 to 235 and can do no better than to quote from this textbook “The clinical manifestation of pineal tumours fall into three groups, those due to hydrocephalus, those due to involvement of the quadrigeminal plate and those due to invasion of the hypothalamus.”  In other words hydrocephalus, disturbance of eyesight and problems with generalised endocrine control such as gynaecological upsets and endocrine upsets.  The authors go on to say “Symptoms and signs of raised intracranial pressure due to hydrocephalus the result of the obstruction of the posterior end of the third ventricle, the upper end of the aqueduct have no special features and usually precede other symptoms.”  This is exactly what was present here.  The authors go on to say ACT scan or MRI identify the condition with an excessively dense and large pineal calcification [on a plain X-ray] make the diagnosis likely.”  Treatment, according to the same authors is “The management of obstructive  hydrocephalus by CSF shunting.  “Ventricular cysternostomy [in effect, opening of the third ventricle into the basal cisterns] has progressively given way to ventriculo peritoneal shunting.  It is noted that this [ventriculo peritoneal shunting] and other drainage procedures in association with an overall early mortality [of surgery] of less than 5% and the five-year survival rates of 60% and 75%”.  The authors go on to say that as far as surgical treatment is concerned “Although practice varies a reasonable approach is as follows:  following demonstration by CT scan of a pineal tumour associated with obstructive hydrocephalus, hydrocephalus is first relieved by CSF shunting.  If there is any question of a vascular lesion such as an aneurism of the great vein of Galen, vertebral angiography is done.  Rarely, vascularity of a tumour indicative of its malignancy may be helpful.


7.7 Following CSF shunting, lumbar CSF should be centrifuged and examined freshly for the presence of neoplastic cells which may confirm the diagnosis of germinoma or pineal blastoma...    If the evidence overall favours the diagnosis of a germinoma [not a pineal cystoma] external radiation is given.  A dramatic and early reduction in the size of the mass and repeated CT scan effectively confirms the presumptive diagnosis and radiotherapy is the definitive treatment with survival extending to many years.”  I should say that this is not the case here.






“If there is no evidence to support the diagnosis of germinoma the choices of management are:-


a]a therapeutic trial or diagnostic trial of radiotherapy

b]direction surgery in an attempt at removal or

c]stereotactic biopsy as a guide to open surgery or radiotherapy....


7.9 Stereotactic biopsy is the most significant recent advance and this in combination with improved definition of CT scanning and MRI will deter the surgeon from embarking on fruitless and damaging surgery if the lesion is an unresponsive tumour such as a malignant glioma.”


7.10 This was a benign tumour where the diagnosis could easily have been obtained by stereotactic biopsy after a cerebrospinal fluid diversion in the form of a shunt.


7.11 I now pass on to Medical Negligence edited by Garfield and Earle.


7.12 Page 274.  Talking about intracranial tumours the authors say “Since facilities for CT scanning and MRI are now widely available in the UK it is very difficult to justify a delay in diagnosis where there are persistent symptoms which may be due to serious intracranial disease even when the physical examination is normal.  Investigations carry no serious risk and once the equipment has been installed the real cost of examination is small...   Skull radiographs on the other hand are of much less value...  It is also important to remember that the interpretation of abnormal findings on imaging studies may at times be as difficult as it is often straightforward. Radiologists who are not seeing abnormal head scans regularly and who have not had appropriate training in a neuroradiology department should be ready to seek more experienced opinion when they are confronted with an abnormality on the scan.”









8 CONCLUSIONS


8.1 What can be said about this case?  I think it is important to separate the various stages in the progress of Mrs B's disease and comment on these where I can.  This may safely be done I think in four areas:-


(1)The General Practitioner. 


8.2  I would say at the outset that although I have trained as a General Practitioner, I would defer to the opinion of an expert General Practitioner in commenting formally for the benefit of the Court.  My view is that it was ill-advised of the original General Practitioner to make a diagnosis of migraine, particularly given the history of headaches, visual disturbance, possible collapse, gynaecological problems in the form of irregular periods and headaches - at the very least, some form of neurological examination should have been undertaken rather than simply diagnosing migraine and prescribing anti-migraine medication.  Matters progressed, however, fairly rapidly and at most only approximately seven hours’ delay occurred before the M Emergency Doctor Service saw Mrs B, that the General Practitioner quite correctly felt that there was a serious risk of intracranial tumour being present, examined the patient, made recording of his findings and referred the patient as an emergency to M Hospital.  Assuming that these are equivalently experienced General Practitioners my view is that the General Practitioner i.e. the M Emergency doctor did what a reasonable General Practitioner should have done, but I would defer to the opinion of a General Practitioner.  I do not believe, however, that any significant additional damage occurred to Mrs B as a result of the slight delay in the first General Practitioner picking up on the intracranial problem.




(2)M Hospital.


8.3 On being presented with Mrs B there are matters of significant concern about what is recorded in the notes.  The suggestion that a lumbar puncture could even be remotely considered in a relatively young woman with a known suggested intracranial tumour at the very least suggests that those who recorded this or made the suggestion require further professional training.  Though it is possible to survive a lumbar puncture with an intracranial mass lesion, the risk of death is so high it should never be undertaken.  This is particularly true where CT scanning is available as is the case here. Fortunately, however, it does not appear that a lumbar puncture was undertaken.  It my view it was inappropriate to suggest that Mrs B could wait until the following day for CT scanning.  An experienced General Practitioner has sent her in as an emergency with headaches, unsteadiness, visual disturbance, blackouts, vomiting [to the point where the nurses looking after during the night noted that they could not even get her to keep down tablets, but had to give all drugs rectally] she had definite neurological abnormalities recorded by the General Practitioner prior to her arrival.  There is absolutely no indication for avoiding a CT scan other than if some form of financial pressure is being placed on doctors by the administrators in the hospital.  In those circumstances the doctor’s ethical duty is to place their patients’ welfare ahead of government targets or administrative convenience.  Unfortunately, in today’s NHS this can be extremely difficult for people to do, but it does not make the failure to obtain a CT scan as soon as possible in a young woman with a suspected tumour any the less indefensible. Had a CT scan been performed expeditiously on her admission, Mrs. B would have been referred to K Hospital a day earlier, and it might have been that a different Consultant would have had hand of her management. In those circumstances, I would expect on the balance of probabilities that she would have been treated expeditiously and appropriately with very much less deficit in the form she now has but it is difficult to put an exact assessment of what these might have been – perhaps no visual defect, less intellectual defect certainly and she would have been much more mobile and able to look after her own day to day care, though perhaps not able to do housework for more than a short period. She would certainly have required much less looking after than she now does. If Mr. C, however, had been the “on take” consultant a day earlier the same series of inappropriate events could be reasonably have been expected to happen.


8.4 When a CT scan was performed the next day it is clear that there was a variable calcification enhancing lesion.  I do not believe [although I do not know the radiologist at M Hospital] that a peripheral hospital general radiologist should be expected to be able to make a tissue diagnosis on the basis of a CT scan.  I also do not think it is out of the acceptable range of normal for that radiologist simply to give the reports to those looking after Mrs B and suggest that they contact a neurosurgeon urgently.  What I cannot explain is why, given the references aforementioned, K Hospital, which acts as referral centre, should be misled by the report that this might be a meningioma - we can see above that it was much less likely to be a meningioma than a pineal tumour.  Be that as it may, even if this had been a meningioma the correct course of treatment would have been to give intravenous dexamethasone, 10-15mg and then an oral dose of 4mg, six-hourly until appropriate treatment could be instituted.  The patient clearly was extremely unwell with a slow pulse, low blood pressure, confused and with evidence of raised intracranial pressure.  The appropriate course of action would be to arrange for her to be intubated and put on a ventilator, with the use of intravenous diazepam to control any fits that were occurring and a longer acting anti-convulsant, possibly phenytoin which takes up to seventy-two hours to become clinically active, and then started on an appropriate oral dose of phenytoin.  At that point the patient should then be transferred expeditiously to the nearest Neurosurgical Unit for further management. I have already commented in my review of the notes that there seems to have been a three to four hour delay in her transfer and that some records make reference to there being difficulty with the intubation, but the anaesthetic notes in her hospital records from M do not seem to make any mention of this.  Given that events were occurring by this stage late in the afternoon, I can see absolutely no reason why this could not have been done and the patient transferred to K Hospital immediately.  It is said that the K team had reviewed the scans - possibly by tele-radiology.  In those circumstances the appropriate course of action would be to advise that dexamethasone be given, to arrange for emergency ventricular drainage and ventriculo-peritoneal shunting to be undertaken on her arrival at K - as she would have already been intubated and sedated there would have been no problem about taking her straight to theatre after appropriate investigation [including a repeat CT or MRI scan at K on her arrival if it was felt necessary] and undertaking surgery there and then.  If ventriculo-peritoneal shunting or external ventricular drainage had been undertaken, I see no reason why she should not then have been able to wake up and appropriate decisions as to clinical management then be made.


8.5 Stereotactic biopsy should be available in all major Neurosurgical Centres - this gives an absolutely unequivocal tissue diagnosis with minimal risk to the patient.  If there was any concern about this being a meningioma, an angiogram could have been undertaken or a digital vascular angiogram or MRI angiograms, all of which could easily have been undertaken at King’s without any delay.  The patient could then have been taken to theatre for such a biopsy, or indeed, an open biopsy after histology had been obtained with no real problem.


8.6 If, for whatever reason it was felt that a biopsy was not to be undertaken there and then, we can see that there was very little to be lost by giving a therapeutic trial of a single shot of radiotherapy to see if the tumour reduced in size.  If it did, stereotactic biopsy could then be undertaken and if, in the highly unlikely event that there is not a single neurosurgical consultant in K Hospital capable of undertaking stereotaxy, this could have been undertaken certainly at the R Hospital or the  N Hospital .  There would be absolutely no difficulty in obtaining such a service simply by the appropriate consultant picking up the telephone and asking one of his colleagues .


8.7 What actually appears to have happened is that there was indecision as to what should be done.  Mr C states that he had never seen a pineal tumour and did not know how to operate on it, yet he did not apparently see fit to ask for the advice of another consultant either in his own Unit or at one of the other  hospitals.  He appears to have little understanding of the importance of being able to talk to other colleagues to ask for advice, or of the fact that there is no shame or face to be lost by admitting that one’s experience is not sufficient to cope with something and asking someone else to deal with it for one.  There is also quite clearly a serious lack of adequate communication with the patient involved.  I think it says a great deal about today’s NHS that a two-page document on the question of resuscitation in the event of cardiac arrest is included in the notes, yet the family quite clearly note that they did not know what was going on.


8.8 It was totally inappropriate to refer Mrs B back to stabilise and be rehabilitated at M Hospital, and indeed, Dr T, the consultant in M Hospital, was clearly unhappy about the poor communication and lack of a definite plan from K Hospital when she was sent back.


8.9 This is even more obvious by the fact that Dr T noted that in spite of a plan being made to have MRI scan done at six to eight weeks after her discharge back to M, she was, in fact, reviewed in Outpatients at K Hospital without an MRI scan being arranged.  In addition, no sense of urgency seems to have penetrated at her review in that it was said that another two or three months could safely be allowed to elapse before an MRI scan was done and further review was undertaken.


8.10 I do not believe we can criticise the M Hospital Rehabilitation ward, as they clearly were unhappy about what was going on, asked for clarification and updating from K Hospital and in effect, were “fobbed off” by a combination of the impression that the family were being troublesome and the patient was simply not improving as fast as she should be because of a failure of rehabilitation.   This was simply not true – the patient was not improving because I do not believe that the shunt was working properly and the underlying tumour remained in situ.  No steroids appear to have been given at all which made the position even worse.


8.11 It is unclear from the notes where the questions of three separate shunting procedures arose - I suspect it was a misunderstanding from someone who thought that a third ventriculostomy meant that a ventriculostomy had been done three times, as opposed to meaning a ventriculostomy into the third ventricle.


8.12 Looking at the scans available to me, I suspect that the Ommaya reservoir was, in fact, incorrectly situated and had been pushed through both lateral ventricles - the whole appearance suggests to me someone of relative inexperience who is not particularly good with their hands.  I do not believe, however, that the patient came to any formal harm from this application of the shunt.


8.13 The question of MRSA is one which does not specifically attach here, other than to say that it resulted in concern that further surgical procedures might be compromised by the risk of infection.  I would say, that the reason MRSA is far more common in Britain than any other country in the Western world is because there is inadequate time for beds to be rested between patients, far too many patients are being put through units in too short a time in order to reach political targets and corners are being cut not just in hand-washing and cleanliness, but simply in the mechanical resting of theatres and beds.  This, however, is not a specific problem here as this patient was within the NHS system and was at the same risk of MRSA as anyone else.




8.14 I am also very concerned about the nature of note-taking in the K Hospital records - because of the large amount of excessive verbiage being recorded by all and sundry, a clear trace of medical notes being taken on a daily basis is impossible to see at a superficial glance.  I have referred above in my review of the notes the fact that at one point ten days went past when not a single medical entry was made in the notes, although we have vast amounts of information as to how many teaspoons of strawberry yoghurt were being fed at each meal to Mrs B.  It must be for the Court to decide whether that is more important than recording the patient’s neurological examination and progress or deterioration.


8.15 Due to the confused nature of the notes it is not clear that operation consent forms are available for each of the procedures, but I presume they must have been.


8.16 On the second admission at the insistence of the Rehabilitation Ward at M to K Hospital it would appear that those looking after Mrs B felt somewhat aggrieved that a second opinion had been asked for.  I have to say Mr C's  documents to the Medical Director show a lack of professional courtesy and make disparaging remarks about Professor P.  Not only are these factually incorrect to my knowledge, it is not an appropriate manner in which one consultant should talk to another, but I also note that Mr C seems to feel that there are differing grades of consultant, some being senior and some being junior.  This would seem to imply a lack of familiarity with the nature of a consultant post, although I would say, that the Royal College of Surgeons’ Training Committee has noted that ten years ago consultants had on average 30,000 hours of operative experience when appointed to posts.  Five years ago that reduced to only 6,000 hours and is now down 5,000 hours’ experience.  This recorded fact in the College of Surgeons’ Training Committee does not appear to cause any particular concern in general, but it is obvious what the effect of that will have on the practical skills of surgeons and their exposure to varying disease.


8.17 A Hospital:  

The only mild criticism I can make of the A Hospital notes and treatment  is that a clinical nurse specialist is dictating discharge summaries - this really should be done by medically qualified personnel and it is not acceptable in my view, particularly in a difficult case like this, for a nurse to send a discharge summary to a consultant physician in another hospital.  This, however, is perhaps only a very small point.  In general terms, although Professor P did not, in fact, undertake surgery and it was another of his colleagues, Mr K, the surgery undertaken was appropriate, timely, carefully carried out and shows quite clearly that the tissue diagnosis was obtained by frozen section on the table and confirmed by paraffin section later on.  The surgical technique confirms the statements made in Greenfield’s Neuropathology about the nature of the tumour, and the outlook in general terms from the point of view of survival is excellent.  Indeed, there does not appear to any indication for chemotherapy or radiotherapy at this stage following removal of the tumour in toto.  




9 PROGNOSIS


9.1 Mrs B has quite clearly been left severely disabled after all of these events. I have been asked to address several points, in particular with reference to the chronology and will attempt to do so hospital by hospital:


M HOSPITAL


9.2 The CT Scan should have been performed as soon as she was seen at M Hospital. She was sent to hospital at 3:30 pm on . It would be reasonable to say that it might have taken till 7 pm for her to be seen and examined in A&E then transferred to the ward, and admission clerking by a Junior Doctor performed. At that point it should have been obvious that an emergency scan was required and this could have been done by 20:30 hours at the very latest.


9.3 This would have shown acute hydrocephalus secondary to a Pineal Region Tumour. This is a Neurosurgical emergency and any reasonable junior doctor should have been aware of this. An emergency referral to a Neurosurgical unit should then have been made, and that unit would accept the patient and operate on the patient as an emergency – the advice would have been to get a blue light ambulance, put the patient on nil by mouth if they were not already, and have theatres put on standby to operate as soon as the patient arrived at the destination unit. As this was K Hospital, I would estimate the arrival time at around 21:30 hours (using Microsoft Autoroute gives a journey time of 49 minutes – the additional time allows for ordering an ambulance etc). I would expect the patient then to be on the table and with a drain in the ventricle by 22:30 hours on  at the latest.


9.4 This means that there was a delay in getting the patient onto the table as a result of delay at M of 24 hours. The effect of such a delay was to allow reduced blood flow into the brain for an extra day thereby causing cell death of brain matter which was totally avoidable, leading to impaired intellectual function, and avoidable increased risk of the subsequent clinical deterioration – it would also have meant that another team would have been on call and another Consultant Neurosurgeon would have had a different management plan.


9.5 The tumour must have increased somewhat in size as tumours grow whilst the patient is alive, but I do not believe the change in size would have been significant over 24 hours – it is the raised pressure inside the head and reduced blood flow as a result which matters.




9.6 The patient should have been given intravenous Dexamethasone as soon as the tumour was seen on the CT Scan in M. I understand that Mr. B reports that Mrs B was intermittently drowsy and vomiting on the evening of  – this is exactly what is expected in patients with acute obstructive hydrocephalus secondary to a pineal tumour. Anticonvulsant Medication is entirely inappropriate – epilepsy does not cause vomiting and the pupil reaction is not a good guide to the patient’s state. The pulse is only of use if the trend is shown to be slowing. The Junior Doctor carrying out these observations simply did not realise what the patient’s diagnosis was – the correct action is to start intravenous dexamethasone and put a ventricular drain in to drop the pressure inside the head because it is this which is causing the vomiting – it is inappropriate and totally indefensible to give antiemetics.


9.7 M Hospital should have put up a drip, given intravenous dexamethasone and if they had noone available to put in an emergency ventricular drain, they could have tried Mannitol an osmotic diuretic which might have reduced the intracranial pressure for a two to four hour period to cover the transport time.


9.10 If the above had been done, then on the balance of probabilities her fits could have been prevented. This would have reduced the pressure inside the head and given Mrs. B a better chance of avoiding complications.


9.11 I have already set out an achievable  chronology for the transfer above.


K HOSPITAL


9.12 Mrs. B should have been (and indeed was) met by the Neurosurgical Team on call on arrival on  at K Hospital and they seem to have prepared for her arrival appropriately in that that an ITU (Intensive Therapy Unit) bed was arranged, but as she arrived at 19:45 hours according to the Medical Notes, I cannot understand why she wasn’t taken straight to theatre and a ventricular drain inserted – Dr. G the Specialist Registrar in Neurosurgery actually says “Plan Emergency EVD” yet  the surgery was not undertaken till approximately 21:20 hours.  On 20th. April 2003 it is recorded in the notes “waiting for team to arrive” and the anaesthetic notes state the surgery took place around 21:00 hours on .


9.13 I can comment as an expert in intubation having worked as anaesthetist for 12 months. Typical causes for difficulty are small jaw, limited jaw opening, large tongue, previous surgery to the pharynx or larynx, vomiting during intubation, loss of light from laryngoscope and many others. There do not appear to be any factors in Mrs. B’s case which would make her difficult to intubate, and I have seen and examined her.



9.14 If Mrs. B had not fitted prior to her arrival in K Hospital, the management should have been the same. The fact she had fitted is simply a further reason for urgent ventricular drainage to be inserted – it is NOT an excuse for further delay.  "Coning" is a shorthand used to describe a sequence of events in which pressure inside the head attempts to shift the brainstem and cerebellar tonsils (the lowest part of the cerebellum) downwards through the large hole at the base of the skull the Foramen Magnum. This results in several events occurring rapidly – the pupils may become fixed and dilated if the nerve supply is caught on the Tentorium (the fibrous sheet at the top of the cerebellum surrounding the brain stem), pulse slowing, blood pressure rising, vomiting, reduction in breathing and disturbed pattern of breathing (Cheyne-Stokes Respiration) before complete respiratory arrest followed within minutes by death from cardiac standstill. Epilepsy may occur in the early stages but is by no means inevitable. There is a range of “coning” from the early stage of mild disturbance of function all the way to death. Looking at the records, it is difficult to suggest terminal coning had occurred in that her blood pressure was within normal limits, her pulse remained steady and we cannot know about respiration because she was being artificially ventilated – the drugs used to paralyse and sedate her would affect her papillary responses in the early stages anyway. On balance, I don’t think she was coning to the point of cardiac arrest when she arrived up to the point of surgery, but she did have dangerously and unnecessarily raised pressure inside her head from the time she was admitted to M, and K missed the opportunity to get that pressure down immediately  by not taking her straight to theatre and inserting a drain but waited “until the notes arrived” and “the team arrived”, a total time of approximately 1 hour 50 minutes. I would agree, however, with Mr. K when he says in his letter of  that she had acute hydrocephalus. That of itself is more than enough reason to take the patient straight to theatre and put in a ventricular drain as an emergency. 


 I do not believe that it should have made any difference to the management of Mrs. B by the time she arrived at K Hospital if she had “gone off” or fitted by the time she arrived there – she needed emergency ventricular drainage no matter what “going off” or fitting just makes the need for drainage even more pressing.


The diagnosis of Pineal Tumour was obvious from the very first CT Scan in M Hospital. Mrs. B’s clinical history was classical as well. The CT Scan is diagnostic in my view of Pineal Germinoma even if teaching students and trying to make them think of alternative explanations for the scan appearances, suggesting meningioma in that position is  clutching at straws and if a student suggested that as a primary diagnosis you would explain that germinomas are many  times more likely as a diagnosis in that area with those scan appearances.



9.15 There are in my view NO circumstances in which Mrs. B should have been managed conservatively unless the aim was to allow her to die untreated. 



9.16 A case might theoretically be made for Pineal region tumours to be treated with radiotherapy and chemotherapy if they are picked up before obstructive hydrocephalus has occurred but that is such a rare event, and would mean that you were treating without having made a tissue diagnosis, and without following the basic precept that the mass of the tumour should be made as small as possible so the treatments of radiotherapy and chemotherapy have the chance to be applied to as little tumour bulk as possible, thereby increasing the chance of successful treatment. Given that Mr. C appears to admit his lack of experience, he should have immediately after inserting a ventricular drain as an emergency handed the patient’s care over to any of the other Neurosurgeons at K Hospital– all of whom would have been able to handle this case. The GMC specifically instructs any doctor that their duty when faced with a condition they feel is outside their expertise is to hand the care of the patient over to someone else who can handle the matter – not to do so is unethical as our duty should always be to the patient’s best interests above all else.


9.17 I am slightly puzzled by the comment of Mr. S, Consultant Ophthalmologist in his letter of 23rd. June 2004 that he “cannot fully explain the patient’s poor visual acuities”. I must defer to the expertise of an Ophthalmologist, but my understanding is that he perhaps means that the refraction of the eye is within normal limits (i.e. the ability of the cornea and lens to focus light on the retina) but Mrs. B’s visual problems arise form damage to the optic pathways and the infarct of the occipital cortex where the information is processed and interpreted. This means that the function of Mrs. B’s vision is poor though the eyeballs themselves are normal.


9.18 On the balance of probabilities, had Mrs. B  been operated on in the manner suggested as a reasonable course of action in Northfield’s Surgery of the Central Nervous System, I think she might have been left with some slight visual disturbance  but nothing like as bad as she now has. Certainly, there would not be any of the confusion and fatigueability described in the notes after surgery and as she shows now. If she had been given a timely ventricular drainage procedure and then had an appropriate stereotactic biopsy followed by either radiotherapy or surgical removal of the tumour I think she would have had some mild memory or concentration difficulties, but would certainly have been able to do relatively straightforward part-time work.  She would not have been as seriously disabled as she now is  and if she had been given steroids prior to her transfer to K Hospital her condition would have improved as well.  I doubt whether it would have been possible to prevent her having fits on arrival at M Hospital, but certainly I do not believe that had she received appropriate ventricular drainage, anti-convulsants and dexamethasone, and possibly Mannitol, she would have had further fits of the type described in the Intensive Care notes at K Hospital.


9.23 This is a difficult case, but I must with regret say that the standard of treatment given to Mrs B in the form of advice over the telephone prior to transfer to K Hospital and her subsequent management at K Hospital fell well below that which would be reasonably expected of a reasonably competent Neurosurgical Unit in the United Kingdom in today’s practice.  I do not believe there is any criticism at all of the treatment at A Hospital, who were presented with a seriously damaged patient for whom they have done their best with no further deterioration occurring.  I have a little concern about the first General Practitioner not examining the patient and recording the examination in the notes, but I do not think that has led to any significant deterioration in Mrs B's outlook or present state.


9.24 I would respectfully suggest that the notes which have been supplied by K Hospital and M Hospital be properly paginated and sorted for the benefit of the Court - it is quite clear that these have either been deliberately or accidentally shuffled and confused and are in no form of order, and indeed, mix different hospitals’ records with other hospitals.



I understand my duty to the Court and have complied with this and will continue to comply with it and I am aware of the requirements of Part 35 and Practice Direction 35, this protocol and the Practice Direction on pre-action conduct.


I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not.  Those that are within my own knowledge I confirm to be true.  The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.







MR D A CAMPBELL, BSc MB ChB FRCS FRCS[Ed]

Consultant Neurosurgeon

© Donald A Campbell 2017