A patient has been awarded £45,000 medical negligence compensation due to a stent – which he was not told had been fitted – becoming embedded in his bile duct after doctors forgot to call him back to have it removed.
The patient, 47, had surgery in May 2017 at Manchester Royal Infirmary to remove his gall bladder. The procedure involved inserting the stent to help fluids flow to his digestive system after suffering from gallstones.
The stent should have been removed after three months, by which time the patient was expected to have made a full recovery.
However, as doctors failed to inform him and his GP that the stent needed removing, and forgot to call him back after three months passed, it was left and became embedded in the surrounding tissues of his bile duct.
It was discovered around two-and-a-half years later the man became unwell an suffered from continued abdominal pain, jaundice and fatigue which made him struggle at work, eventually going to A&E when experiencing increasing shortness of breath.
Scan discovered blocked stent
An ultrasound scan of the abdomen identified the blocked stent, which doctors did not initially removed.
Instead the patient had to undergo the fitting of three new stents into the original to support and ensure the bile duct was able to continue draining fluids, over an 18 month period.
Doctors finally replace the original with a fourth and final temporary stent, which was then later removed itself.
The patient suffered repeated ongoing symptoms for long periods between these procedures over close to two years, undergoing four additional procedures which would have been avoided had the original stent been removed when it should.
Manchester Royal Infirmary had no records as to why the original stent could not be removed in either of the three procedures before it was finally replaced.
Illness had impact on work and home life
With all stents now removed, the man, now 52, says he feels back to full fitness, but during the two years of continuing fatigue and illness, he needed a significant amount of time off his work, a significant factor in changing his employment twice over that period.
As part of a legal claim led by solicitor Matthew Gascoyne, of medical negligence specialists Hudgell Solicitors, Manchester University NHS Foundation Trust admitted breach of duty of care in failing to arrange a follow-up removal of the stent, and failing to make the patient and his GP aware of plans to remove it after three months.
It also admitted failings in allowing the stent to become embedded in the man’s bile duct, and for not keeping clear and detailed notes as to the decision-making which saw doctors choose not to remove the original stent, but insert three others into it, before it was finally replaced after almost two years.
The man says he was never informed of a stent being fitted at the time of his initial procedure, and that both he and doctors were surprised to find it almost two years later.
“When I was first back in hospital it was very worrying as I’d been really lethargic whilst we were on holiday and cold and shivering, even though it was a hot summer’s day. I was really ill but for a couple of days the doctors had no idea why.
“When they found the stent on an ultrasound it was a surprise to them as they had no documentation about it, and I had no idea as I’d never been told it had been fitted.
“I was told that a new stent needed fitting into the original, but after around six months I again felt the same. I’d describe it as a grey period, where you are never feeling 100% and you gradually get worse and worse.
“I was getting really quite poorly every six months, then it would be every three to four months, and each time it would take me longer to recover. I was told I could need the surgery for the rest of my life.
“I’m not someone who wants to be critical of the NHS as I was involved in a serious accident when I was younger and they saved my life, but in this case I was let down and I couldn’t face years of continued suffering and surgery. That’s when I decided to make an official complaint and contacted solicitors.
“After I’d made my complaint, and they’d been made aware of my legal representation, they did find a way to remove the original stent, and then leave me with no stent at all, which has made a huge impact to my quality of life.
“I was also called at one stage by somebody from the hospital to tell me that, after what happened in my case, the system had been changed and a register of all stents fitted was introduced and monitored at all times, to prevent something like this happening again, which is obviously positive.”
Error is classed as a ‘Never Event’ by NHS
Mr Gascoyne said the error is classed as a ‘Never Event’ by NHS England – mistakes which are ‘wholly avoidable’ if the proper checks and procedures are followed.
“This most basic error had a significant impact on my client’s health for more than three-and-a-half years as he suffered recurrent bouts of symptoms from the blockage of his bile duct, including abdominal pain, jaundice, fatigue and general feelings of being unwell,” he said.
“It impacted on his quality of life at home, at work, and on his leisure time. As part of the legal claim we instructed an independent consultant gastroenterologist who was of the opinion that, had the original stent been removed after three months, as intended, he would have suffered no further symptoms at all.
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