This case involves a 34-year-old man addicted to heroin, who was found unresponsive in an alleyway on a warm Sunday evening, with his left leg tucked underneath his body. There was also evidence he had been assaulted, with multiple abrasions and bruising over his face and body and marked swelling of his left leg.

He was taken to hospital by ambulance, by which time, having received IV fluids, his level of consciousness had increased, although he remained confused and agitated.

Despite the warm day, upon examination the patient had a low body temperature with a cold, pulseless left leg. Blood tests taken immediately on admission revealed an acidosis – evidence of severe renal damage with dangerously high potassium and muscle enzyme levels. X-rays of his limbs were clear, although he had fractured ribs.

The admitting doctor suspected a compartment syndrome of his leg, which would indicate severe swelling of the muscles, leading to a lack of blood supply and consequential death of muscle tissue. He therefore informed the orthopaedic service, and the patient was admitted to ICU for ventilation.

A CT scan was carried out, which was highly suggestive of compartment syndrome. However, the orthopaedic consultant, who was on call at home, did not accept the diagnosis as there was no fracture and suggested observation through the night.

The following morning, the patient was seen by a different orthopaedic consultant, who correctly diagnosed the condition and organised emergency surgery. Unfortunately, the leg could not be saved and an amputation was performed.

A serious incident investigation was carried out by the hospital, which concluded there were significant shortcomings in the standard of his medical care, on the basis of which, the patient took an action in medical negligence.

His lawyers, having read the hospital findings, felt they had a watertight case and commissioned reports from both A&E and orthopaedic consultants. These experts did not consider causation any further, and their reports were supportive. The lawyers therefore commissioned further reports from a neurologist (as he had phantom limb pain), a rehabilitation expert and a forensic accountant, all of which represented a considerable financial outlay by the firm.

The plaintiff’s legal representatives were surprised when lawyers acting for the hospital consultants indicated they would mount a robust defence. They therefore requested a secondary screening report from a medico-legal expert.

This expert noted the patient had a low body temperature on admission, with evidence of severe damage to his kidneys and muscles. He inquired further into the timing of the injury, and the police investigation revealed the assault had occurred in the early hours of the morning, some 14-16 hours prior to admission.

Successful surgery to address an acute compartment syndrome is required within 6-8 hours of onset and, therefore, even if the correct diagnosis had been made and appropriate action taken following admission, on balance of probabilities the outcome would still have been amputation.

Therefore, in spite of clear breaches in the duty of care by medical staff, there was no consequential damage “but for” the breaches, and an action in negligence would be unlikely to succeed.

This case exemplifies the need for an early screening report by an experienced medico-legal expert, even in cases that appear on face value to be clearly negligent. This would have saved time and effort, as well as a considerable financial outlay by the legal advisers.

MDU figures for 2020 show that less than one in six actions in medical negligence actually succeed, with the vast majority failing on the grounds of causation. It must be remembered that subsequence is not the same as consequence.

Initial screening is, therefore, essential to manage client expectations at an early stage. This avoids unnecessary effort and costs for all concerned. Too many cases are taken to court with no chance of success. This is stressful for both the client and their legal adviser, and indeed for the medical personnel involved.

For fast and effective screening of all potential medical negligence cases, contact Peyton Medico Legal Services now on +44 (0)28 87724177, or email [email protected]