Otorhinolaryngology litigation in England: 727 clinical negligence cases against the National Health Service.

INTRODUCTION: Litigation against the National Health Service (NHS) in England is rising. The aim of this study was to determine the incidence and characteristics of otorhinolaryngology clinical negligence claims in England. METHODS: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otorhinolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and surgery. RESULTS: A total number of 727 claims were identified with an estimated potential cost of £108 million. Out of these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148 923. Head and neck surgery was the subspecialty with the highest number of claims (n = 313, 43%) and highest cost (£51.5 million) followed by otology (n = 171, £24.5 million) and rhinology (n = 171, £13.6 million). Over half of claims were associated with an operation (n = 429, 59%) where mastoid surgery (n = 46) and endoscopic sinus surgery (n = 46) were equally associated with the greatest number of claims. The most frequent causes for clinical negligence claims included failure or delay to diagnose (n = 178, 25%), failure or delay to treat (n = 136, 19%), intra-operative complications (n = 130, 18%) and failure of the consent process (n = 107, 15%). DISCUSSION: Clinical negligence claims in otorhinolaryngology are related to several different components of patient management and are not limited to postoperative complications. This study highlights the importance of robust pathways in out-patient diagnostics and the consenting process in order to deliver better patient care and reduce the impact of litigation. Keywords informed consent, malpractice, clinical negligence claims, litigation, otolaryngology.

Pelvic actinomycosis: a forgotten cause of pelvic pain.

Actinomycosis is an invasive and suppurative anaerobic infection, which can develop in the pelvis. This occurs most commonly as a result of prolonged use of an intrauterine device. The constellation of signs and symptoms associated with its typical clinical presentation include palpable mass, weight loss and malaise. It can be misdiagnosed as a result and often as a malignant process. Left unrecognised, pelvic actinomycosis can lead to sequelae such as severe abscess, fistula formation and even infertility. Removal of the intrauterine device and a prolonged course (6-12 months) of antibiotic treatment form the cornerstone of management. Surgery can be required in select cases. This article provides an overview of pelvic actinomycosis, including its background, presentation, investigations and management.

Caecal perforation from TB and the Law of Laplace.

A 43-year-old man presented to the hospital with haemoptysis. When worked up, his history and examination were highly suggestive of pulmonary tuberculosis (TB). He subsequently developed a massive upper gastrointestinal bleed and underwent an emergency laparotomy, which revealed a massively dilated caecum measuring ∼20 cm in diameter. The caecum had perforated due to acute decompensation of intestinal TB. Though common in developing countries, TB is rare in the UK, especially the intestinal kind. The most striking feature of this case is, however, the size of the caecal distension caused by the tubercular inflammation and subsequent perforation-something unheard of in the literature. This massive caecal distention would be explained by the Law of Laplace. In conclusion, massive distension and caecal perforation are possible consequences of intestinal TB, especially in the 48-72 h immediately after starting anti-tubercular therapy.