June Greenhorn (ap) V. South Glasgow University Hospitals Nhs Trust
| Jurisdiction | Scotland |
| Judge | Lord Uist |
| Neutral Citation | [2008] CSOH 128 |
| Published date | 05 September 2008 |
| Court | Court of Session |
| Date | 05 September 2008 |
| OUTER HOUSE, COURT OF SESSION [2008] CSOH 128 | |
| OPINION OF LORD UIST in the cause JUNE GREENHORN (AP) Pursuer against SOUTH GLASGOW UNIVERSITY HOSPITALS NHS TRUST Defender ________________ |
Pursuer: MacAulay QC, Miss Sutherland; A & W M Urquhart
Defenders: Stephenson; R F Macdonald
5 September 2008
Introduction
[1] The pursuer, who was born on 1 June 1964, is the mother of three children. She underwent a hysterectomy in December 1994. She thereafter developed symptoms of incontinence, for which she attended four sessions of physiotherapy at Law Hospital, Carluke. In about March 1999 she was referred by her gynaecologist there to Dr Ian Ramsay, Consultant Obstetrician and Gynaecologist at the Southern General Hospital in Glasgow. He performed urodynamic studies which showed that she suffered from genuine stress incontinence (GSI) and detrusor instability. GSI is caused by prolapse of the urethra below the pelvic floor. Detrusor instability is over-activity of the bladder muscle. As the pursuer's GSI did not respond to physiotherapy Dr Ramsay offered her a colposuspension operation. She underwent a colposuspension at the Southern General Hospital on 26 August 1999. In the course of the operation she suffered serious blood loss, which ceased only after pelvic vessel embolisation had been carried out following an emergency angiography which had revealed leakage of blood from a branch of the right iliac artery. She avers that her blood loss was caused by uncontrollable haemorrhage from the branch of the right iliac artery due to one of the doctors who performed the operation having damaged the right ileopectineal vessels as a result of having negligently inserted sutures near those vessels (and not into the ileopectinael ligament closer to the symphysis pubis) and too laterally deep in the right pelvis. The blood loss resulted in a neurological injury.
Colposuspension
[2] Colposuspension is an operation which is designed to cure urinary leakage arising from GSI. It is designed to restore the normal position of the bladder, which may have undergone some degree of prolapse and involves drawing the bladder neck up through the pelvic floor muscles so that they can work effectively to stop incontinence. The tissues at the neck of the bladder which lie at the top of the vagina are hitched up by means of stitches to a ligament on the front of the bony pelvis called the ileopectineal ligament. When the stitches are tightened the urethra is restored to its normal position and incontinence should resolve. In about 2003 colposuspension was effectively superseded by tension free vaginal tape procedure through keyhole surgery whereby needles are placed through the tissues attached to a tape which provides the hammock which the vagina did with the colposuspension. That procedure has itself been significantly modified to the obturator tape procedure and has become the new gold standard in the treatment of GSI.
Arteries and veins
[3] An artery is a blood vessel which carries blood away from the heart. All arteries, except the pulmonary artery, carry oxygenated blood. The walls of arteries contain smooth muscle fibres which contract or relax under control of the sympathetic nervous system. A vein is a blood vessel which conveys blood towards the heart after it has circulated through the tissues off the body. All veins, except the pulmonary vein, carry deoxygenated blood from the tissues.
The pursuer's operation
[4] The pursuer's colposuspension was carried out by Dr Kalaivani Lingam, then a Specialist Registrar in Obstetrics and Gynaecology, under the supervision of Dr Hassan Omar Mohammed Ali (Dr Hassan), then an Associate Specialist in Obstetrics and Gynaecology. They were the only doctors who gave evidence about events at the gynaecological operation. Dr Grant Urquhart, Consultant Radiologist at the Southern General Hospital with a special interest in intervention radiology, gave evidence about his involvement in carrying out the embolisation procedure which stopped the pursuer's bleeding. Expert evidence about how a colposuspension should be carried out came from Dr Alan Brown, formerly Senior Consultant in Obstetrics and Gynaecology at the Royal Infirmary of Edinburgh, and Mr Gerald Jarvis, Consultant Obstetrician and Gynaecologist at the BUPA Hospital in Leeds with a special interest in urogynaecology.
[5] The evidence led established that in the course of the operation there were two separate sources of blood loss, the second more significant than the first. The first occurred in the area of the right ileopectineal ligament. The pursuer avers (at p 8D), in accordance with the operation note, that "right ileopectineal vessel bleeding was noted and sutures were applied to this area" and (at p 13C-D) the defenders admit that. It is not suggested that this first source of blood loss was causally related to the pursuer's injury. The second and significant source of blood loss was from a branch of the right internal iliac artery. There were two views from the expert witnesses about how this damage occurred. According to Dr Brown it occurred when Dr Lingam moved out of the operating field to some extent while applying sutures to the vaginal wall. The final position adopted by Mr Jarvis was that it occurred when a suture was being applied to the ileopectineal ligament and the needle penetrated into a muscle in the pelvic floor, causing damage to the artery. Such an explanation was not pleaded by the defenders on record. Mr Jarvis accepted in evidence that Dr Lingam was negligent if she moved outwith the operating field to cause damage to the artery while applying sutures to the vaginal wall. It is the pursuer's case that the second source of blood loss occurred because Dr Lingam moved outwith the operating field when she applied the second vaginal suture and thus caused damage to a branch of the internal iliac artery. She avers, not only that Dr Lingam was negligent in carrying out the operation, but also that she lacked the necessary experience to carry it out and that Dr Hassan failed to supervise her properly when she was carrying out the operation.
Dr Lingam's qualifications and experience
[6] Dr Lingam's curriculum vitae is 7/4 of process. She graduated MB ChB from the University of Glasgow in 1987. She subsequently acquired the qualifications of Fellow of the Royal College of Surgeons of Edinburgh (1992), Member of the Royal College of Obstetricians and Gynaecologists (1996) and Diploma of the Faculty of Family Planning (1999). At the time of giving evidence she was a consultant obstetrician and gynaecologist at Queen's Hospital, Burton, Derbyshire, having previously held a similar post in Rotherham from 2001 to 2004. Before that she was a specialist registrar in Glasgow. So far as her training was concerned, she first worked from August 1987 to January 1988 as a Medical Junior House Officer at the Victoria Infirmary in Glasgow, and then for the following six months as a Surgical Junior House Officer at Glasgow Royal Infirmary. She was a Senior House Officer in Obstetrics and Gynaecology at Stobhill Hospital, Glasgow from August 1988 to January 1989, at the Southern General Hospital from February to July 1989, and at the Glasgow Royal Maternity Hospital from August 1989 to July 1990. From August 1990 to July 1991 she was a Senior House Officer in Urology at Glasgow Royal Infirmary, during which period she learned the procedure for carrying out a colposuspension. She carried out on average two colposuspensions each week because at that time in Glasgow all incontinence work was done by a urologist. For the first six months she assisted in the procedure but towards the end of that period she undertook the procedure. Over the latter six months she was lead surgeon in six procedures and assistant in another six. From August 1991 to July 1992 she was a Surgical Senior House Officer at the Glasgow Victoria Infirmary. From August 1992 to July 1993 she was a Senior House Officer in Urology at Glasgow Royal Infirmary, during which time she was involved in about 20 colposuspensions, in about half of which she was lead surgeon. From August 1993 to November 1993 she was a Senior House Office in Obstetrics and Gynaecology at the Royal Alexandra Infirmary, Paisley, but did not undertake any colposuspensions during that time. From December 1994 until April 1996 she was a Senior House Officer in Obstetrics and Gynaecology and from May to July 1996 undertook research in urology at Glasgow Royal Infirmary and had no involvement in colposuspensions during that time. From August 1996 to October 1996 she was a Senior House Officer in Obstetrics and Gynaecology at Stobhill Hospital, during which time she was involved in about two colposuspensions, in neither of which she was the lead surgeon. From November 1996 until July 1997 she was a Specialist Registrar at Stobhill Hospital, during which time she had no involvement in colposuspensions. From August 1997 until July 1998 she was a Specialist Registrar in Obstetrics and Gynaecology at Falkirk and District Royal Infirmary, during which time she was an assistant surgeon in one colposuspension. She then moved to the Queen Mother's Hospital in Glasgow as a Specialist Registrar in Obstetrics and Gynaecology from August 1998 until July 1999 and during her year there performed one colposuspension as a lead surgeon. She began working as a Specialist Registrar at the Southern General Hospital on 1 August 1999 and left there on 29 September 1999. On 26 August 1999 she performed a colposuspension on another patient before she carried out the operation on the pursuer. She performed both these operations as lead surgeon. She had no recollection whether she had done any colposuspensions between 1 and 26 August, but thought that if she had done so she would probably have remembered. Nor had she any recollection whether she had assisted in any colposuspensions between 1 and 26...
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