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The importance of reviewing a patient’s medical history

A 73 year old woman has been awarded £6,000 by Royal Berkshire NHS Foundation Trust after they failed to review her medical history thoroughly.

In March 2000, Jennifer Butler underwent a laparoscopic cholecystectomy under general anaesthetic at the Royal Berkshire Hospital for acute cholecystitis.

In March 2015, she returned to the same hospital for an ultrasound scan of her abdomen. It was noted that the gallbladder was not well visualised but appeared to be contracted around gallstones.

A couple of months later, in June 2015, Mrs Butler was seen at Churchill Hospital for upper GI surgery. This appointment was to consider bariatric surgery but also to review the ultrasound scan to look at gallbladder issues. It was noted that should Mrs Butler have a recurrence of cholecystitis then she would undergo a cholecystectomy.

The following month, Mrs Butler was seen at the Spire Dunedin Hospital for bariatric surgery. A discussion regarding the laparoscopic cholecystectomy took place and Mrs Butler’s GP was asked to send a referral letter.

In September 2015, Mrs Butler underwent a gastric bypass under general anaesthetic at the Spire Dunedin Hospital. The following month, Mrs Butler was advised to have a laparoscopic cholecystectomy due to the gallstones seen on the ultrasound scan.

In January 2016, Mrs Butler underwent a pre-operative assessment at the Royal Berkshire Hospital. The Nurse noted that the gallbladder was taken out previously but queried if this was correct. There was no further discussion regarding the previous removal of the gallbladder.

In February 2016, the MRCP study report noted that on review of the previous ultrasound scan “the gallbladder is absent…”.
In June 2016, she was scheduled to undergo a laparoscopic cholecystectomy for symptomatic gallstones under a general anaesthetic. However during surgery, “no apparent gallbladder“ was found and the procedure was subsequently aborted.

Following the procedure, Mrs Butler developed post-operative bradycardia. She was transferred to the Coronary Care Unit and observed overnight.

Mrs Butler contacted Fletchers Solicitors to act on her behalf.

The Defendant admitted liability and made an offer of £6,000 which Mrs Butler accepted.

Hannah Andersen, Litigation Executive at Fletchers Solicitors, said: “This case highlights the importance of thoroughly reviewing the patient’s medical history prior to procedures. Had this simple check been done then Mrs Butler would have avoided the aborted surgery and associated complications. I hope this case encourages the Trust to put stricter procedures in place before surgical procedures are performed.”

Hannah Andersen

Case Solicitor

Hannah is litigation executive within the team she is responsible for drafting letters of claim. She will have an in-depth understanding of the case in order to draft the letter of claim, which will outline the formal allegations we are making. Hannah proactively chases a response to these letters and evaluates the quantum of the case. She will also collate and consider the customer’s losses, and negotiate with the Defendant if an offer of settlement is made.

Key Case Details

Mrs Butler underwent a general anaesthetic and aborted surgery for gallstones, despite her gallbladder previously having been removed. Her medical history had not been reviewed correctly prior to the procedure.
We investigated Mrs Butler's claim and achieved a settlement of £6,000.

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