Foreword by Dr Leisa Freeman
Cardiology consultant and MDU council member
Concerns can be raised about any aspect of a doctor's work, irrespective of speciality or experience, or whether the treatment was carried out privately or within the NHS. While this article examines claims against cardiologists working in independent practice, we hope it will help guide colleagues in all areas of this speciality.
There has been an increase in the use of interventional techniques in cardiology this century and many cardiologists now spend much of their time doing procedures. It is not surprising, therefore, that there has been an increase in the number of claims related to complications of these procedures.
However, claims don't arise just as a result of complications following interventional procedures. As this article shows, a significant number of claims against cardiologists who are members of the MDU resulted from general concerns about treatment or a delay in diagnosis of both cardiac and non-cardiac conditions.
Complications occur just as frequently in NHS hospitals as they do in private hospitals, so it's important to make sure that clinical risk processes are of the same high standard, wherever you work. The key to helping patients understand the risks they take when agreeing to cardiac procedures is to ensure that consent processes are clear and well documented. If you are doing the procedure, make sure you have discussed risks and benefits fully with the patient and have documented it. Even recognised complications of procedures can lead to litigation if patients feel they have not been fully informed.
Consultants who work in the NHS are indemnified for medico-legal claims made against their employer. However, if the case results in a complaint to the GMC or if a death is reported to the coroner, NHS indemnified hospital doctors may need the support of a medical defence organisation. Medico-legal costs are high, as illustrated in this article, and this has driven up costs of indemnity. But the financial cost is really negligible compared with the inevitable personal cost of a claim or complaint felt by the doctor involved.
Claims against cardiologists
More than half of all consultant cardiologists currently practising in the UK are MDU members1, and around one third of these have needed to seek our assistance in the last 10 years with a wide range of matters including GMC complaints, coroners' inquests, employers' disciplinary processes and clinical negligence claims in both NHS and independent practice. Many more have called our 24-hour advice line with matters ranging from patient complaints to complex ethical scenarios.
Claims against cardiologists are less common compared to some other surgical specialities (such as orthopaedic surgery), but the size of damages awards and claimants' solicitors' legal costs can be considerable. Even claims that are successfully defended can take several years to be resolved, which can be very worrying for those involved.
Here we examine medical negligence claims against cardiologists working in independent practice over a recent 10-year period. All the cases involve MDU members and have been formally closed as they have concluded.
Outcome of cases
We classify a claim as either a claim for compensation or notification that solicitors have been instructed by a patient to investigate a potential claim. Over 80% of cases we examined were successfully defended, with no admission of liability and no payments of either damages or claimant legal costs.
Outcome of claims
- Successfully defended: 82%
- Settled: 18%
The level of compensation paid in clinical negligence claims is not determined with reference to the seriousness of the clinical allegations. Instead, it reflects the cost of restoring the claimant to the position they would have been in if the negligence had not occurred.
With large damages payments, much of the compensation paid is to fund the future care of badly injured patients or to compensate them for loss of earnings.
The highest damages payment by the MDU on a cardiology claim settled in the review period was well over £2 million for an alleged failure to diagnose possible hypertrophic cardiomyopathy. The patient sustained brain damage as a result of a cardiac arrest, and the costs of the care the patient would require in the future were therefore substantial.
In another case relating to a delay in the investigation of the cause of chest pain, damages of over £1 million were paid, primarily driven by the claimant's loss of earnings. More typically, compensation payments ranged from £10,000 to £250,000.
It is also worth noting that the costs payable to claimant's solicitors can be substantial, often totalling hundreds of thousands of pounds for a single claim.
Claims against cardiologists are less common compared to some other surgical specialities, but the size of damages awards and claimants' solicitors' legal costs can be considerable.
Reasons for claims
- Incorrect or inadequate treatment - 20%
- Delayed diagnosis or treatment - 17%
- Angiography - 15%
- Ablation/transoesophageal echocardiography - 15%
- Drug reactions - 10%
- Pacemaker insertion - 10%
- Miscellaneous - 13%
Incorrect or inadequate treatment
The most common allegations against MDU cardiologist members concerned alleged incorrect or inadequate treatment, which made up nearly 20% of notified claims.
The conditions affected were wide ranging, and covered both outpatient and inpatient care. Examples of cases involving outpatient care included incorrect advice given to a patient with valvular heart disease resulting in premature death, misinterpretation of exercise tolerance tests and inadequate treatment of ischaemic heart disease. Cases involving inpatient care included inadequate cardiac monitoring resulting in delayed detection of cardiac arrest.
However, of those cases where treatment was alleged to have been incorrect, fewer than 15% were settled by the MDU.
Delayed diagnosis or treatment
The other most common allegations against MDU cardiologist members, comprising 17% of claims notified, were due to an alleged delay in diagnosis or treatment.
These included delays related to cardiac conditions such as bacterial endocarditis, and coronary artery disease and delays for unrelated conditions including malignancies and berry aneurysm. Cases where it was alleged that diagnosis or treatment was delayed were more likely to be settled than most other types of claims, and settlement was agreed in just over 40% of these cases.
Just over 10% of claims involved drug reactions, including complications following treatment with gentamicin and amiodarone, as well as adverse reactions to flecainide. Other claims alleged vasovagal episodes due to cardiac medication. None of the drug error claims resulted in settlement by the MDU.
Complications following angiography featured in 15% of claims. The complications were sometimes relatively minor, such as pseudo-aneurysm at the site of femoral artery puncture or complications following use of radial artery access. In other cases the consequences were much more serious, such as stroke following angiography.
Ablation and transoesophageal echocardiography
A further 15% of claims followed ablation for arrhythmias. The concerns raised by patients included burns, a stroke following ablation, post-operative infection, and cardiac tamponade. All but one of these claims were successfully defended.
Three claims alleged an oesophageal perforation following transoesophageal echocardiogram, and two of these were successfully defended.
Just under 10% of claims were brought after complications associated with pacemaker insertion, half of which were settled. The concerns raised included unnecessary pacemaker insertion, concerns about the lack of an adequate consenting procedure and faulty devices.
There were ten claims where it was alleged a patient's death resulted from a delay in diagnosis of a non-cardiac condition such as lung cancer. However, only one case featured an allegation that the death was as a direct result of a cardiological procedure being undertaken.
Manage the risk
There are steps you can take to manage common risk factors and reduce the risk of misunderstandings which can lead to a claim.
- Ensure you fully document your discussions with patients and the reasons for choosing a particular treatment pathway. This helps with continuity of care and can be useful in defending claims.
- In some cases, the alleged negligence was a result of a recognised complication of a procedure, emphasising the importance of having a thorough consenting process. Make sure the patient is aware of the risks, benefits and complications of the proposed procedure as well other therapeutic options. These should be carefully documented.
- Supporting information like leaflets and information sheets can help a patient's understanding. The use of these should be documented in the records.
- Consent should be obtained by an appropriate member of the team and, ideally, by the cardiologist undertaking the procedure.
- Be aware of the GMC's recently updated guidance on Decision making and consent, and other relevant guidelines such as those from NICE.
- Keep your eyes open for non-cardiac conditions either presenting with cardiac-like symptoms or existing alongside cardiac pathology. It may be difficult to defend missing a serious underlying non-cardiological condition in patients you see for cardiological problems.
- To avoid adverse drug reactions, it's important to check and document any allergies. If a reaction occurs, take appropriate steps.
- If things go wrong, be open and honest with the patient by providing an explanation of what has happened and the likely short and long term effects. Say sorry and get advice from the MDU if you believe the incident triggers the organisation's duty of candour requirements.
It can be very distressing to find out a patient is bringing a claim against you. If you face a claim you can be assured that the MDU's expert claims handlers and medico-legal advisers understand how stressful this is and the importance of mounting a robust defence of your position. The MDU will defend claims whenever possible. We involve members in the conduct of their cases and will always seek your consent to settle a case.
While claims numbers have remained steady in recent years, the cost of claims has spiralled. This is not due to clinical standards but to a deteriorating legal environment which the MDU is campaigning to reform. You can see more at themdu.com/faircomp