Necrotising Fasciitis Claim For Compensation
A case study concerning the treatment of Amanda Willis, who attended the Emergency Department of Brockhurst Hospital NHS Trust on 16th, 19th and 21st April 2007.
Amanda was discharged home on the first two attendances. However, on 21st April a diagnosis of necrotising fasciitis (flesh eating disease) of her right buttock and perineum region was made and she required in-patient hospital care. This is how her situation developed...
First Hospital Visit - 16th April
On about 12th or 13th April 2007, Amanda Willis started to get pain around the area of her coccyx. This pain continued and by 16th April she was in so much pain that she could not sit down or walk properly. She called an ambulance. By this stage she could barely walk and was unable to sit. Amanda also could not lie down on her front. After arriving at A & E on 16th April 2007, she informed a doctor that she had been experiencing pain in her coccyx for the past few days. She said that she was unable to sit or stand. She had her blood pressure and pulse checked. She said that she was not actually examined in the area of her coccyx and was discharged home with no advice or warnings given.
When Amanda got home all she could do was to lie down on her front. She could not lie on her back and she could not sit.
The A & E records for 16th April from the Brockhurst Hospital Trust record that Amanda went to A & E on 16th April 2007 at 23.13 hours. It records that she had been brought in by ambulance. The triage information states that she had developed right buttock pain three days previously, which was increasingly painful, continuous and non-radiating. She was unable to weight bear, but had no loss of sensation. Interestingly also there was no history of trauma which there usually is in cases of necrotising fasciitis.
Her base line observations were recorded. Her blood pressure was 102/62, pulse 97, respiration 18, temperature 37, oxygen saturation 98% on room air. A further set of observations had been documented under ambulance handover with blood pressure 103/88, plus 87 regular, respiration 12, oxygen saturation 100%.
Amanda was examined by a senior house officer at 0045 hours on 17th April 2007. It was documented that she had gradual onset of right buttock pain over the previous three days aggravated by movements. She was relieved by lying still on her front. She felt nauseous with pain, but had no weakness, numbness or tingling. She was unable to weight bear due to pain, but had no bladder/bowel disturbance, no altered perineum sensation, no back pain and no history of trauma.
On examination she was in obvious discomfort, but the diagnosis was of musculoskeletal pain and she was administered with diclofenac per rectum and prescribed and dispensed with oral paracetamol, ibuprofen, codeine phosphate and diazepam. She was discharged home.
Second Hospital Visit - 19th April
By 18th April, Amanda was in so much pain that she stayed at home because she could not go to work and spent the day lying face down on her bed taking pain killers. By the next day, 19th April, she was in a bad way. Her right buttock was swollen to a huge size and was red in colour. She could barely put her tracksuit bottom on. An ambulance was called and she was taken straight to hospital.
On this occasion her buttocks were examined, but a misdiagnosis of constipation was made and she was discharged home with laxatives. No comment was made by the doctor who examined her about the difference between the sizes of her left and right buttocks and again she was given no advice or warnings.
The hospital records confirm that Amanda attended A & E on 19th April 2007 at 09.21 hours. She had been brought in by ambulance. Her presenting complaint was documented as back pain. It was noted that she had been complaining of back pain for one week and that she had been seen in A & E three days previously and sent home with medication, although there had been no relief. On arrival her pain score was 9 out of 10 and she had last taken pain killers at 06.30 hours. Her base line observations again were recorded. Blood pressure 77/44, pulse 114, respiration 18, no temperature was recorded, oxygen saturation 99%.
Amanda was examined by a doctor at 10.10 hours. The following is documented : presenting complaint back pain; right sided lower back for 8 days; seen in Accident & Emergency 3 days ago; discharged home with diclofenac and codydramol; no improvement; unable to open bowels for 7 days due to pain; urinating normally; no weakness/numbness/tingling in the legs; not eating much; history of constipation. On examination in pain; tender right lumbar area; no tenderness over lumbar spine; lower limb examination was reported to show normal muscle power, tone and reflexes on both sides; light touch sensation normal in lower limbs; anal tone intact. Impression: mechanical back pain plus constipation.
Care plan to give analgesia and send home with laxatives and to continue pain killers for back pain. She was prescribed oral diazepam and voltarol.
Following the second discharge from the Accident & Emergency Department on 19th April, Amanda continued to experience pain in her buttock. She was in so much pain she was in tears and could barely walk. On 21st April she went to a chiropractor who told her to go immediately back to Accident & Emergency.
Third Hospital Visit - 21st April
The hospital records confirm that on 21st April she had lower back pain radiating to her right leg. She had not opened her bowels for 8 days. Observations were blood pressure 78/51, plus 110, temperature 36.1, oxygen saturation 95%. She was examined by a doctor at 15.30 hours. By now she was in severe pain and unable to sit. She wanted to lie down. A sketch was done of the right buttock and perineum region with areas showing necrotic (flesh eaten) tissue around the right buttock with redness, swelling, very tender, smelly in odour.
Necrotising Fasciitis Diagnosis
The correct diagnosis was made on the third occasion of ischio rectal abscess plus necrotizing fasciitis. Amanda was then started on intravenous antibiotics including flucloxacillin, benzyl penicillin and metronidazole. Amanda was then referred to the surgical on-call team.
The surgical on-call team noted a large area of necrosis affecting the right buttock and the right vulva. She was resuscitated by intravenous fluids and antibiotics. She subsequently underwent an operation under general anaesthetic for extensive debridement of the necrotic tissue in the right perineum and the right buttock area. After surgery she was transferred to the intensive therapy unit.
Amanda was diagnosed as being in septic shock, which is why she was admitted to the intensive therapy unit. A second debridement operation was carried out on 22nd April 2007 when a loop colostomy operation was also performed. A further third operation for more debridement was then performed on 24th April.
Amanda was then readmitted for elective closure of the loop colostomy operation on 15th February 2008.
More About Necrotising Fasciitis
Necrotising fasciitis is also called “flesh eating bacteria”. It is a rare infection of deep layers of the skin and subcutaneous tissues. The most common organism which causes this infection is Group A streptococcus. Other bacteria that can cause necrotising fasciitis include Vibrio vulnificus, Clostridium perfringens, Bacterides fragilis, etc. These infections usually begin locally and can arise spontaneously in previously healthy people. The infection is characterised by severe pain at the site of the initial infection rapidly followed by tissue necrosis. The affected area is at first very painful without any grossly visible signs. During the progression of the disease, the tissue starts to become swollen and painful with redness. The skin becomes hot. The skin colour then changes to violet with blister formation followed by necrosis (death) of the tissues.
Patients with necrotising fasciitis may have a fever and appear very ill. The diagnosis is made by taking a history of the pain which is disproportionate initially with a lack of external physical signs. If necrotising fasciitis is suspected, the initial treatment is with IV antibiotics and if the condition continues it will be necessary to carry out surgical exploration of the area.
Preparing Amanda's Case - Medical Evidence
In this case we obtained an opinion from a consultant in emergency medicine. The expert said that it was essential on 16th April 2007 when Amanda first presented to the hospital that a visual inspection and palpation of the right buttock and surrounding areas, to include the perineum and the genital areas, be performed to rule out a local pathology, for example, an infection.
Had an examination of the buttocks and the surrounding areas been carried out, it would have revealed tenderness in the right peri-anal region. This finding should have then led to a rectal examination, which would have been painful on the right side and would have led to a suspicion of an ischio-rectal abscess. Amanda would then have been referred to the on-call surgical team in the early hours of 17th April 2007.
Amanda had no physical examination of the buttocks and genital areas on 16th/17th April 2007 by the examining doctor. Failure to carry out this examination constituted sub-standard care.
When Amanda went back to A & E on the second occasion on 19th April 2007, the expert we instructed commented that the doctor examined her buttocks but made no comment on the difference between the sizes of her left and right buttocks. His concern regarding her care on this date was that her blood pressure had been noted to be extremely low, i.e. 77/44 and 91/53 with a fast pulse rate of between 117 – 114. Having a low blood pressure with a fast pulse rate is suggestive that a patient is unwell and showing signs of developing septicaemia (septic shock). The examining doctor failed to take action knowing about these abnormal observations. The appropriate course would have been to carry out a full physical examination to identify the cause for the low blood pressure. Had this happened, it is likely that the examination would have revealed tenderness with swelling and redness in the perineum and buttock areas. Even if that examination had been normal, it would still have been sub-standard care to discharge Amanda home on the day with such a low blood pressure. What should have happened is that Amanda was referred to an on-call surgical team with a view to hospital admission.
Our expert said that by this stage Amanda was very ill and that had she been admitted it is likely that the cause of her septic shock would have been diagnosed as due to an abscess in the perineum. Early diagnosis and treatment on this date would have avoided some of the complications and extensive surgery that were subsequently required.
It was only when Amanda attended the Accident & Emergency Department for the third time on 21st April 2007 that the correct diagnosis of necrotising fasciitis of her right buttock and perineum was made. It was only then that she was given appropriate treatment, to include intravenous antibiotics and fluids, followed by extensive debridement surgery as a result of the necrotising fasciitis.
Second Medical Expert - Professor In Microbiology
The next expert we instructed was a professor in microbiology. She said that the infection was caused, as is usual by unidentified coliforms and unidentified mixed anaerobes. The offensive smell of the discharge that was noted is characteristic of anaerobic infection and the anaerobes were the major pathogens in this particular infection.
The necrotising infection involved not only the skin and fascia but also muscle, thus it was also a myositis. Necrotising fasciitis and myositis never respond to antibiotics. They require urgent and often repeated, debridement, as happened in Amanda's case. Whether antibiotics are of any benefit is questionable, although they are always given. Nevertheless, if all the necrotic tissue is not excised during the debridement procedures the infection will continue to progress.
In the professor's opinion, Amanda's infection did not start with necrotising fasciitis, which was probably not present when Amanda was first seen in Accident & Emergency on the night of 16th April 2007. The infection was initially a right ischiorectal abscess. If the ischiorectal abscess had been diagnosed on the night of 16th April then this would have been drained the next day, 17th April. If this had been done then necrotising fasciitis would not have occurred at all.
The low blood pressure and tachycardia on 19th April were suggestive of severe sepsis and developing septic shock. These findings meant that necrotising fasciitis was developing by then and Amanda would have needed more than simple drainage of the ishciorectal abscess by that stage. Some of the necrotic tissue would have required debridement. However, the extent of the debridement at that stage would have been markedly less than that which was subsequently required on 21st April 2007.
Necrotising fasciitis can progress very rapidly indeed and within 48 hours can become much more extensive and this is what happened with Amanda Willis.
Third Medical Expert - Colorectal Surgeon
The next expert we instructed was a colorectal surgeon to give an opinion as to what would have happened to Amanda had she been diagnosed earlier.
The colorectal expert said that had she been referred to a surgical team on 16th April 2007 a competent surgical assessment would have diagnosed a probable ischio-rectal abscess. Amanda would have undergone simple drainage of the abscess on 17th April and would probably not have gone on to develop necrotising fasciitis. She also would not have required a colostomy and would not have needed admission to the intensive care unit.
The colorectal expert also said that had Amanda been referred for a surgical opinion when she next went to A & E on 19th April that a reasonably competent surgical assessment would have diagnosed a large ischio-rectal abscess. At this stage Amanda already had the signs of systemic sepsis consequent on infection due to the abscess. He said that although she may have developed a small area of necrotising fasciitis by this stage, in his opinion it would have been fairly minimal, because if she had had extensive necrosis on 19th April it is unlikely she would have survived until 21st April. Had she been managed competently by the surgical team the abscess would then have been drained. It is possible that a small area of tissue would have had to be excised, which would have left her with a slightly bigger wound than had surgery been undertaken two days earlier. However, she would not have required a colostomy and would not have required admission to the intensive care unit and her post-operative stay and recovery would have been significantly quicker. She was also unlikely to have had any residual deficit with regard to her bowel function.
Once the diagnosis was correctly made on 21st April of an ischio-rectal abscess and necrotising fasciitis, Amanda's care once she was referred to the surgical team could not be faulted. However, by this time she had developed extensive necrotising fasciitis of the right buttock, which required extensive and multiple debridements and a defunctioning colostomy. As a result of the severe infection she developed septicaemic shock and required a period of admission to the intensive care unit and undoubtedly by then had suffered a life threatening illness. She required multiple surgical operations, a prolonged period in hospital and a prolonged recovery period.
Unfortunately, Amanda has been left with a residual large soft tissue deficit as a result of the extensive surgery which was needed to deal with the necrotising fasciitis. Amanda's bowel function was also compromised as a result of the injury to her anal sphincter, which was caused by the necrotising fasciitis and the surgery which was required to deal with it.
Fourth Medical Expert - Plastic Surgeon
The next expert we instructed was a plastic surgeon. He examined Amanda and described in his report that a large part of her right buttock muscle which had been affected by the infection had had to be excised. Although the wounds had healed spontaneously over a period of several months, she had been left with extensive scarring and deformity of the buttocks.
The colostomy which she had to have was closed about a year afterwards, but she was left with extensive and unsightly scarring.
At the time the cosmetic surgeon saw Amanda, he considered that the scarring was fully mature and would not improve further with time. He considered that the abdominal scar caused by the colostomy and its subsequent closure could be improved with cosmetic surgery. However, the extensive scarring of the sacrum and perineum could not be improved surgically and would remain permanent. Furthermore, the injection of filler materials or insertion of buttock implants would not, in all probability, have been successful.
Settlement Of Amanda's Claim
Despite all of this evidence the NHS Trust defended the claim for sometime before the evidence that we obtained proved Amanda's claim beyond doubt. Her claim was settled for the sum of £125,000. Reading through this story and the pain experienced by Amanda, no one could say that she did not deserve at least this amount in settlement of her claim.
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Need Advice About Necrotising Fasciitis?
If you believe that you or a member of your family have been infected, please contact us for early legal advice. All initial enquiries are completely free of charge.
Please call us free on 0800 234 3300 (or from a mobile 01275 334030) or complete our Online Enquiry Form.
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