Lane v Worcestershire Acute Hospitals NHS Trust & Anor [2017] EWHC 1900 (QB) (24 July 2017)

C was born on 18 July 1953. In September 2010, she had multiple risk factors for ischaemic heart disease, being then a morbidly obese 57-year-old ex-smoker with a family history of premature ischaemic heart disease who suffered both hypertension and elevated cholesterol. (paragraph 34)

On 30 September 2010 C suffered a myocardial infarction… She was treated by a rescue angioplasty by D2 before being transferred back to D1 during the morning of 1 October 2010. (paragraph 1)

During the early hours of Saturday 2 October 2010, C developed ischaemia to her right arm. This condition was correctly diagnosed by D1 at 02:30, but she was not transferred back to D2 until about 08:50. The consultant vascular surgeon performed a brachial and radial thrombectomy under local anaesthetic at 21:10… (paragraph 2)

Unfortunately, the clot in the radial artery recurred and, despite further surgery on 13 October, C developed dry gangrene. Her right arm was subsequently amputated above the elbow on 9 November 2010. (paragraph 3)

C originally complained of negligence by both D1 and D2… the three allegations of negligence that are now pursued by C:

First, C alleges that the advice given by D2 cardiology registrar at 02:30 on 2 October 2010 was negligent.

Secondly, she alleges that D2 was negligent in not taking her to theatre at 12:40 on 2 October and in delaying surgery until 21:00.

Thirdly, she alleges that D2 was negligent in not carrying out thrombectomy of the ulnar artery and completion angiography. (paragraph 4)

C confirmed… did not pursue the case against D1. (paragraph 5)

D2 denies negligence. In short, it responds that C was seriously ill and that her cardiac condition remained unstable. It argues that it was reasonable to seek to optimise C’s medical condition before transferring her and then before carrying out surgery. While accepting that the ischaemia was a medical emergency that required vascular surgery, the D2 contends that C presented a significant surgical risk and that it had to prioritise “life over limb.” As to the operation, the D2 argues that it was reasonable not to carry out completion angiography, especially in a seriously ill cardiac patient, and that it is not standard vascular practice to clear the ulnar artery upon successful thrombectomy of the radial artery. (paragraph 6)

C claims that but for D2’s negligent management of her ischaemic arm, amputation would have been avoided. There is evidence of a number of cumulative causes of amputation; some of which, it is common ground, were not negligent and others which it is said arose by reason of D2’s negligence. (paragraph 25)

clear evidence that C was suffering some further cardiac event from about 22:30 [1 October 2010]. (paragraph 47)

The issue was about how to manage this acutely ill cardiac patient with an ischaemic arm… (paragraph 53)

the rough rule of thumb… that surgery within 6 hours of the onset of total ischaemia should save a limb but that, after a delay of 12 hours or more, it becomes likely that there will be a loss of some tissue or amputation. (paragraph 76)

faced with this unstable cardiac patient who was in the midst of some further cardiac event and who was bradycardic, hypotensive and in cardiogenic shock and who had just presented with an ischaemic arm, a reasonable and responsible body of cardiologists would seek first to stabilise the patient by increasing her intravascular volume while monitoring her progress with a view to subsequent transfer for vascular surgery. (paragraph 88)

a reasonable and responsible body of vascular surgeons would have delayed surgery until C’s cardiac condition had been stabilised, alternatively until it became clear that no more could be done. (paragraph 186)

a reasonable and responsible body of vascular surgeons would not have also carried out an ulnar thrombectomy upon achieving reperfusion through thrombectomy of the brachial and radial arteries. (paragraph 191)

a reasonable and respectable body of vascular surgeons would not have carried out completion angiography (paragraph 195)

D2 achieved successful reperfusion of the arm even though surgery was delayed until after 21:00. This is not therefore a case of failed delayed surgery but of surgery that, although initially successful, was unable to sustain blood flow to C’s arm

C’s arm would not have been saved even if D2 had operated earlier. An earlier operation would no doubt have also led to the successful reperfusion of the arm, but, for the reasons already set out, such result would not have been sustained. (paragraph 212)

even if I am wrong to dismiss the allegations of delay and inadequate surgical technique in this case, I find that any such negligence did not cause the subsequent amputation. (paragraph 213)

I therefore dismiss this claim against both defendants. (paragraph 215)