Medicolegal -as expert, not defendant!!

Transcription

1 Medicolegal -as expert, not defendant!! Professor Pat Price Ralston Paterson Professor of Radiation Oncology, Christie Hospital, University of Manchester Management in Radiology RSM rd July 2009

2 Professor Pat Price MA MD FRCP FRCR Specialises in gastrointestinal cancer and radiotherapy treatment. t. Research interests in Radiotherapy, Molecular Imaging for studying cancer biology, and growth rates of tumours. Committed to evidence based medicine-useful for medico-legal work Dealt with over 500 medico-legal reports over the last 18 years, (70% for the Plaintiff and 30% for the Defence). Co-editor of the standard UK oncology textbook "Treatment of Cancer" now in its 5th edition. Chairman, UK Academic Clinical Oncology & Radiobiology Research Network & Past President, British Oncological Association.

3 Hammersmith Hospital-London Royal Postgraduate Medical School PET at the Medical Research Council s Cyclotron Unit

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5 Welcome to the Medicolegal World Going on all around you Legal departments- hospitals, MDU, MPS Increasing litigation-no no win no fee Patients often want to see things don t t go wrong again Patients have a right to take legal action as much as they have a right to good medical care

6 Reasons to be positive Legal action is an integral part of improving care If doctors get involved we have a hope of getting the balance and not degenerating to US style defensive medicine Probably should be part of medical training How to avoid legal action How to get involved as an expert witness

7 The Legal Test Have to prove both Liability: Failure of care Causation: The failure resulted in detriment Most cases fail on one or the other Even if proven, most cases settle out of court as the legal costs are greater than the value of the claim

8 Failure of Care Would a reasonable body of doctors have done the same? Promotes evidence based medicine Informed consent-gmc guidance Good record keeping solves most problems Not seniority specific Who is responsible for the failure?

9 Causation Need to have a greater than 50% chance of the outcome happening On the balance of probability (ie( >50% chance) if the negligence had not happened the outcome would have been y Is y worse than what did happen? What is the value of the detriment Surprisingly low value claims in the UK Not punitive damages, just compensation

10 What to avoid in radiology Commonest mistakes Missing something Acting outside your area of expertise Failure to take responsibility-go over old Xrays Not being pessimistic enough if a spiculated lesion, say it may be cancer Organisational failures-document who you rang etc

11 What to do if a claim is made against you Contact your Trust Legal department or defence union Go over the case and be as honest as possible-put put your hands up if an error Never alter records Keep calm-it is only a financial claim, not a GMC claim

12 Why become an expert witness Good CME training Extremely interesting-like a second opinion / problem based learning Interesting working with smart lawyers Can genuinely help: Patients move on Doctors prepare their defence Uncover organisational failures-improve improve

13 How to be a good expert witness Get some training-courses available Get on a Expert witness Registers BMA guidance - how to run a practice Be accurate, impartial and not dogmatic Don t t be bullied by lawyers/other experts Don t t stray outside your area of expertise Build up a reputation as independent

14 Cancer Cases LIABILITY Delay in diagnosis Treatment-incorrect or badly given CAUSATION Delay - Unnecessary treatment - Increased pain and suffering - Decreased survival (< 50% 5 year) Treatments - unnecessary side effects/complications

15 Delay in diagnosis of tumours GP referral delay (usual) Government White Paper The new NHS-Modern, Dependable guaranteed everyone with suspected cancer to be able too see a specialist within 2 weeks Hospital (less common) Failure of investigation Administrative error (filing of histology) Failure of the MDT meeting Working outside expertise-nurse practitioners

16 Colorectal Cancer: Guidelines for Urgent Referral All ages Rectal bleeding WITH a change in bowel habit to looser stools and/or increased frequency of defecation persistent for 6 weeks. A definite palpable right-sided abdominal mass A definite palpable rectal (not pelvic) mass * Over 60 yrs Rectal bleeding persistently WITHOUT anal symptoms Change of bowel habit to looser stools and/or increased frequency of defecation, WITHOUT rectal bleeding and persistent for six weeks. Iron deficiency anaemia WITHOUT an obvious cause (Hb < 11 g/dl in men or < 10 g/dl in postmenopausal women). Low Risk Patients with the following symptoms and no abdominal or rectal mass, are at very low risk of cancer: Rectal bleeding with anal symptoms (soreness, itching, lumps, prolapse, pain. Change in bowel habit to decreased frequency of defecation and harder stools. Abdominal pain without clear evidence of intestinal obstruction. Age 60 years is considered to be the maximum age threshold. Local Cancer Networks may elect to set a lower age threshold (eg 55 years or 50 years)

17 Growth Rates of Cancer Measured as time for tumour volume to double -VDT 1 cell-26/30 doublings = 1cm 36 doublings approx kills patients Back calculation: volume of a sphere Evidence based from untreated tumours Varies with tumour type: teratoma>breast>colon>carcinoid carcinoid

18 Half empty glass Natural History of Growth Doublings Cells Diameter um microscopic 20 1 x mm microscopic 30 1 x cm Detectable XR 35 1 x cm Average Diagnosis 40 1 x cm Death

19 Growth rates of GI tumours Upper GI Pancreas the fastest Oesophagus/gastric/hepatobiliary hepatobiliary- 2years Carcinoid-up to 20years Lower GI Colorectal- VDT 130days, 3.7year H/O mets Anal -fast years

20 Survival Rates Used to express the probability of survival Most published literature will provide ranges For most legal cases 5 year survival without disease is taken as cure,, as probability of relapse after is < 50% 100% Survival Curves Probability 50% > 50% 50% < 50% Time (years)

21 The Problem with Oncology Cases A vast range of cancer, some curable, some not A lot of oncology dealt with by non-specialists Many assume that early detection means cure - not always the case Many patients/relatives cannot accept a diagnosis of cancer or have feelings of guilt Most patients need an explanation rather than litigation

22 Cases the claimant could win A reasonable amount of time between a delay in diagnosis and action being taken, e.g. years Radiology result is filed/not acted upon Radiology misread and tumour missed Administrative delays -no action was taken on diagnosis A short time interval between diagnosis and curative treatment in some cases, e.g. Gastric Lymphoma Long standing conditions which have similar complaints to cancer but which are overlooked, e.g. rectal bleeding

23 Cases that might be won A known pre-disposing condition has been ignored, e.g. FPC ulcerative colitis etc. Failure of a screening programme difficulties in apportioning blame, guidelines on screening eg Barrett s Failure to instigate screening when appropriate, e.g. ulcerative colitis at 10 years Guidelines have not been followed? were there guidelines at that time

24 Cases which can usually be Defended If metastases were diagnosed earlier all along they were not curable and treatment is only palliative Diagnosis only delayed by a matter of weeks Fast growing usually incurable cancers pancreatic cancer Often late presenting cancers gastric, oesophageal cancer

25 Points from the patients and relatives Patients anxiety over the effect of treatment many patients can continue chemotherapy/radiotherapy and still go to work Side effects do occur but their severity can be reduced Denial and guilt from patients and relatives Angry relatives who simply need explanation Patient concealing information from relatives even up till death

26 Summary Embrace the medicolegal world Protect yourself by good practice and good documentation Reports like s-can be read by anyone Think about becoming an expert witness