Brady v Southend University Hospital NHS Foundation Trust [2020] EWHC 158 (QB) (31 January 2020)

C claims that a delay in diagnosing an actinomycosis infection in 2013 led to surgical drainage of a psoas abscess in February 2014… [1]

On 24 May 2013, C underwent a laparoscopic appendectomy at the D Hospital. During the procedure, “acute appendicitis, turbid free pelvic fluid” were found, and a standard appendectomy with pelvic suction and washout were performed. [3]

On 1 August 2013, C attended her general practitioner with acute epigastric pain which had started the previous night. She was referred to the surgical assessment unit… on the same day. She reported central abdominal pain and pain in the left upper quadrant. Diagnoses of gastritis, gallstones and pancreatitis were considered, and investigations ordered. Blood tests showed raised inflammatory markers (white cell count and CRP). [4]

On 2 August 2013, an ultrasound scan was reported as “heterogenous ill-defined mass in epigastric region anterior to pancreas”. A CT scan for further evaluation was recommended. [5]

On 5 August 2013, a CT scan (“the first scan”) was reported… as follows: “There is a mass in the right upper quadrant. There is hyperdense and contains areas of fat and there is some localised hyper-vascularity. It is separate from the large bowel and stomach. The appearances would be consistent with omental infarction rather than a primary mesenteric/omental neoplasm. There is no evidence of intussusception. After clinical discussion with the Surgical SPR, I gather she has had a recent laparoscopic appendectomy which makes the diagnosis of omental infarction most likely. Comment: omental infarction”. [6]

C’s pain had improved by then and the radiological ‘most likely’ diagnosis was accepted by the clinicians. Accordingly, on 6th August 2013, C was discharged home. [7]

C’s pain had improved by then and the radiological ‘most likely’ diagnosis was accepted by the clinicians. Accordingly, on 6th August 2013, C was discharged home. [8]

On 18 September 2013, C was reviewed who noted a “craggy lump” in C’s upper abdomen, and that she was still in pain. She was immediately admitted… she was noted to have ongoing spasmodic abdominal pain, and blood tests confirmed raised CRP and white cell count. C was commenced on a 7-day course of intravenous antibiotics, Augmentin. The initial plan was to undertake a diagnostic laparoscopy the following day. However, at 19:20 hours… C was reviewed decided that a CT scan should be performed. [9]

On 20 September 2013, the “second scan” was reported: … Report: Lung bases are clear. Liver looks unremarkable. There is a large mass which is vascular grossly related to the posterior aspect of the right abdominal wall. This requires for the urgent evaluation. This is causing gastric outlet obstruction. Also encasement of the right transverse colon. There is nodularity in the entire abdomen. And this requires further urgent evaluation. This case has been discussed with the referring consultant. [10]

C’s condition had improved with the antibiotic treatment, C was discharged home. [12]

…a subsequent letter 17 October 2013, stating:”I sent the scans… one of the Upper GI Surgeons, to look at after discussing the case with her. She reviewed the CT scans with several of the GI specialist radiologists… they also feel that this diagnosis of spontaneous omental infarct is correct”. [13]

On 16 February 2014, C attended A&E… A CT scan the following day demonstrated a left-sided psoas abscess containing gas and fluid, which was drained surgically. The previous abdominal mass was no longer visible. Microbiological analysis confirmed the infecting organism as actinomyces… [16]

C’s case that the omental mass observed on the first and second CT scans was an actinomycosis infection and not an omental infarction….That appropriate action would have resulted in the omental mass being biopsied and a diagnosis of actinomycosis being made. C contends that the source of the psoas abscess, found in a different part of the Claimant’s abdomen, was the same. C’s case is that the omental mass did respond to antibiotics provided and resolved, but that they did not prevent the development of the psoas abscess. It is agreed that if the omental mass was an infection, the infection would have resolved completely with a course of intravenous antibiotics, followed by a year of oral antibiotics. Accordingly, the subsequent deterioration and treatment in February 2014 would have been avoided. [17]

D’s case is that the C probably suffered two rare conditions, an omental infarction and actinomycosis. D acted reasonably in concluding that the abdominal mass in 2013 was probably an omental infarction and treating it conservatively without undertaking a biopsy. [18]

an early biopsy in 2013 would have revealed infection and avoided C’s catastrophic illness in February 2014, in my judgment the criticisms of D are not made out. Accordingly, the C’s claim is dismissed. [57]