Mr D. A. Campbell BSc. MB. ChB. FRCS. FRCS(Ed).
Park View, Leek Road, Cheadle, Staffordshire, ST10 2EF.
Tel/Fax: 01538 757435
Email: Bellerophon@msn.com
MEDICAL REPORT
The report is addressed to the Court by whom the matter is to be heard
RE:Mr XXX
DATE OF BIRTH: 12th. Never 3333
OCCUPATION:On Permanent Disability
ADDRESS: Acacia Avenue
Anytown
DATE OF EXAMINATION:3rd Never 4444
AT: ROOMS
SUBJECT OF REPORT:Causation in a matter of Alleged Medical Negligence
INSTRUCTING PARTY:Suem & Grabbitt
REFERENCE NO: EVERYTHING
OUR REFERENCE NO:DAC.STL.2079999999
DOCUMENTS SEEN:Photocopied General Practice records
Hospital Records from AA and BB andCC Hospitals
Disability and Care Reports
Physiotherapy records
Appendix I
Mr D A Campbell FRCS (London) FRCS (Edinburgh)
Graduate of Edinburgh University Medical School.
Full-time NHS Consultant Neurosurgeon for 12 years until 1996 and thereafter remains in active private clinical practice in Harley Street and continuing in private practice at the Sussex Nuffield Hospital in Brighton.
Special interest in Cervical and Spinal Surgery, missile injuries to the head and spine, and stereotactic surgery.
Involved in postgraduate lecturing to doctors and lawyers involved in medico-legal issues
Extensive experience in medico-legal work, having given written or oral evidence in excess of 5000 cases.
Trained and experienced with regard to CPR procedures, and has wide experience in compliance with orders of the Court regarding medical evidence in personal injury cases.
Experienced in producing medico-legal reports relating to personal injury claims, being instructed by claimant and defendant representatives, as well as receiving joint instructions.
Member of Society of Expert Witnesses
Listed in:
Expert Witness Directory
UK Register of expert Witnesses
Expert Witness Website
Full G.M.C. RegistrationNo. 1333231
Medical Protection SocietyNo. 95188
Waiting list approximately four weeks. Available for consultation at private consulting rooms and hospitals in Birmingham, Brighton, Derby, Gloucester, London, Manchester, Newcastle-under-Lyme, Norwich, and Sheffield.
01/05
In addition to examining Mr XXX, who was accompanied by his wife, I have had access to additional documents including disability and care reports, updated General Practice records up to 8th April 2008, as well as physiotherapy records from the AA, BB and CC Hospitals and the HA Health Centre.
Mr. XXX tells me that in the past he has had some episodes of occasional low back pain, but never enough to put him off work nor has he ever prior to the events to which this report refers had any sciatica. He is currently on the following medication: Amitriptyline, Ezetimire, Buprenorphine, Soluble Aspirin, Bisoprolol, Pregabalin, Amlodipine, Atorvastatin and Tramadol.
He tells me that on the night of nth. Never, he went to bed as he had developed some back pain after helping to move some heavy furniture. He can remember passing urine normally before going to bed, and thinking that he had overdone things but that after a good night’s sleep he would feel better. His back pain became more sever and he woke early the next morning, and was not aware of any need to pass urine. He struggled to get up because of severe pain down the back of both legs, and was aware that he felt numb around his penis and scrotum. His wife had taken a sleeping tablet, so he he tried not to wake her, but crawled to the bathroom where he found he was unable to pass urine. He then went downstairs as it was around 5 in the morning, and decided he would telephone the physiotherapist he had seen in the past about his back pain to ask for advice around 9 o’clock.
He did so, and was advised that he just had overdone things, and to put frozen peas on his back. At no time can he remember being asked about being able to pass urine.
He did so, and by midday, he was no better but his legs were becoming numb, so his wife managed to get him into their estate car and took him to AA casualty, where he was briefly examined, no Xrays were taken and he was told he had bad back strain and should rest and take painkillers, and contact his GP the next day if he was no better.
The next morning, he telephoned the emergency GP around 7 who came to the house, examined his reflexes and sensation in his feet, and told him that he needed muscle relaxants, prescribed diazepam and advised him to contact his own GP the next day if matters had not improved. By 9 the next morning, his wife did so and his ownGP Dr. AB came to the house, took a history, determined that no proper urine had been passed for nearly 24 hours, and immediately called an ambulance and spoke to the local Orthopaedic Surgeons on call at BB hospital.
When he arrived at BB hospital, he was examined, but was told that the MRI scanner was busy and that he would have to wait till the evening for a scan because there were patients already booked and they could not be cancelled.. It is recorded in the notes that perineal sensation was abnormal, a urinary catheter was passed, and 2.8 litres of urine drained.
By 6 pm, a scan was undertaken which showed a large central L5/S1 disc which had migrated to behind the body of the L5 vertebra and was causing severe compression of the Cauda Equina. The radiology handwritten report states “urgent decompressive surgery would seem necessary” but it appears that no-one looked at the scan or report until the next morning, when after the ward round, contact was made with CC hospital, Neurosurgery Department, who asked for emergency transfer.
He underwent decompressive surgery around 12:00 as he had not been starved and had been given breakfast by BB hospital prior to transfer!
At operation a “massive” free fragment of disc was removed by laminectomy, but unfortunately his symptoms of pain were improved, his bladder function did not, in spite of three months rehabilitation at DD hospital. He was discharged home with arrangements for him to have continuing physioptherapy, and help from te local pain clinic.
He tells me he has continued to try to get help with physiotherapy and attends a Pain Clinic who have tried steroid injections, transcutaneous morphine, clinical psychology and a TENS machine and really none of the these has resulted in a significant improvement in his symptoms, although Mr XXX says that he has learned effectively to live with his symptoms and simply tries to get on with doing as much as he is physically capable of. He tells me that he has not been able to obtain employment since I last saw him, although he has tried to persuade employers to allow him to work from home on a part-time basis, but does not appear to have been successful in this.
- COMPLAINTS ON THE DATE OF EXAMINATION
At 3rd June Mr XXX complains of the following:
1.1He still has constant low back pain with aggravation of his symptoms on walking.
1.2He still has bladder and bowel urgency, but is now controlling himself with self-catheterisation once a day. His bowels still give him problems and he tells me that he never feels that it is entirely empty.
1.3He continues to have absent sensation during sexual function.
1.4His left leg continues to be painful with altered unpleasant sensation on the back of the leg and the sole and loss of sensation in that area. He feels that the right leg is slightly better than it was, but still has disordered sensation on the right side as far as the heel and sole of the foot is concerned.
1.5The feeling of sitting on a boulder is still present and is static.
1.6He still has difficulty in walking with the light off and has to hold on to the furniture.
1.7His perineal sensations remain altered and he still has to shower after opening his bowel.
1.8He has altered sensation to his clothing from the waist down, but he has learned to try to ignore this and it does not affect him quite as badly as it did.
1.9He still has difficulty bending or turning over with pain in his back, aggravated by coughing or sneezing.
1.10He continues to complain of constant tiredness.
1.11He is unemployed now, having been made redundant on ill health grounds on 2nd February 2006.
1.12He is limited in his walking and has to use a stick. In general terms he feels that all of these symptoms are now static and of all these symptoms he feels that what he describes as the nerve pain, i.e. the disordered unpleasant feeling in his left leg principally is the most intrusive and the worst symptom
- EXAMINATION ON 3RD JUNE 2008
2.1Examination reveals Mr XXX to be alert and orientated in time, place and person and fully aware of the purpose of this report. His blood pressure is 140/90 and he remains overweight.
2.2Central nervous system. Cranial nerves: He has Grade 1 hypertensive changes. There has been no change in his sense of smell. His pupils are equal and react to light and accommodation; fundi are normal. Eye movements are full, equal and normal with no complaint of diplopia or nystagmus.
Facial sensation and movement are equal, symmetrical and normal. Tuning fork tests and lower cranial nerves are normal.
2.3Peripheral nervous system. In the upper limbs power, tone, sensation, co-ordination and reflexes are normal. He uses one stick to walk and is able to transfer himself from the chair to standing and on and off the couch without sticks, but his wife had to assist him with dressing, particularly from the point of view of his trousers and shoes. Power in the lower limbs reveals 5/5 hip flexion, 4/5 weakness of flexion and extension of knees on both sides, 3/5 dorsiflexion of the foot on the left and 4/5 on the right and plantar flexion is 4/5 on both sides [5/5 full power, 2/5 ability to move the effect of gravity removed and 0/5 equals complete paralysis]. I have also measured the circumference of his legs in the mid hamstring and mid calf area and these show 63cm on the right and 62cm on the left and 44cm on the right and 42cm on the left respectively. Tone reveals no ankle clonus. Sensation reveals altered sensation over the S1 dermatome and direct examination of the perineum continues to show left-sided altered sensation from S3 into the anal margin. Scrotal sensation is similarly affected. Rombergism is weakly positive, but I did not attempt heel/toe walking given his combination of weakness and altered sensation. Reflexes in the lower limbs reveal that the quadriceps reflexes are present bilaterally, although they are reduced and both ankle jerks are absent bilaterally, even with reinforcement. Similarly a plantar response cannot be obtained. Straight leg raising is approximately 80 degrees on the right and 60 degrees on the left and is consistent with his movement when he is standing. Direct inspection of the back reveals a well-healed surgical scar as described previously and the normal lumbar lordosis in his back is somewhat flattened with clear muscle spasm.
- REVIEW OF MEDICAL RECORDS
3.1There are General Practice records in total between AAAA to BBBB There is an entry in XXXX when he was noted to have had a headache since starting Lisinopril [this is a medication for high blood pressure and is known to be associated with a risk of headaches]. He was started on antidepressants in the form of Fluoxetine in XXXX and by later that year it was noted that he was still significantly depressed. By August 2005 he was noted to be back at work, but “struggling++” and was noted to only have done ten half days in the past month. His General Practitioner has included a very telling comment, “Turned down for part of DVLA, told it was because of my report! I’m fed up with the DVLA! They have no insight into people’s difficulties and medical conditions”. I must say that I would agree entirely with the General Practitioner’s approach here; he also notes in the same consultation that Mr XXX had been to see me in Harley Street and was told that his pain would never go away. What in fact I said was that his pain will never go away completely, although it was worthwhile being assessed by a Pain Clinic to see if they could help and in fact the General Practitioner did refer him to a Pain Clinic on that same consultation. He then seems to have been seen by the Physiotherapy Department in BB Hospital and also was noted to be seen by the continence nurse in XXXX. He continued under his General Practitioner’s care and the XXXX Pain Clinic throughout XXX and seems to have started with the General Practice physiotherapists at some point in XXXX as well and he thought that this was helping a little bit, but by no means curing his symptoms. By February XXXX it was noted that he was having problems even with intermittent self-catheterisation and was aware of incomplete bladder emptying; Mr XXX tells me that in fact he has not been advised by the Urologist to catheterise on a daily basis, which he now is.
3.2Attached hospital correspondence contains some reference to his blood pressure control as well as correspondence from various members of the Pain Management Team and the Spinal Injuries Unit in CCCC Hospital. In a letter of XXXX it was noted by the Cardiology Clinic that he had recently been made redundant on ill health grounds. Essentially the correspondence continues to confirm significant problems with pain and depression. I also note that a hand physiotherapy discharge form noted that his mobility was limited due to incomplete spinal injury; this is literally true, but it is important not to be misled by thinking that this was some kind of trauma accident; the spinal injury arose from the cauda equina syndrome due to the events referred to in my original report. In XXXX it was felt that it would be worthwhile trying specialist back stability exercises and hydrotherapy to try to help him. He was noted to have tried clinical psychology, which seems to have helped, but he found that a TENS machine was difficult and awkward and not very affective. He seems to have been discharged by the physiotherapists in XXXXX with an open appointment to return if he got worse. By XXXXX [I think in fact that this is a misprint and should be January YYYY] it was noted that the clinical psychologist was trying hypnosis to help him.
3.3There are physiotherapy notes from CCCC Hospital, which essentially confirms that they were trying to offer physiotherapy in XXXX and YYYY; I am slightly puzzled by one of the handwritten notes from XXXXX in which it was stated that there was no pain or wound tenderness or guarding, but it is noted that there was altered sensation; this simply cannot be true because Mr XXX has quite clearly had constant pain. It was also noted in another physiotherapy note of XXXXX that his sensation was improving, but he was still numb. The physiotherapy notes from the Health Centre again seems of standard form and relates to physiotherapy in XXXXX and trying to mobilise him and produce as much mobility as possible.
3.4There are two separate reports, one from SSA , as far as nursing care is concerned and one from JJSSDisability Assessment Services. Both of these reports are of course prepared by relevant experts [A and B respectively] and clearly I would defer to their particular expertise, but I would simply say that I have read these reports and they do seem to be perfectly reasonable. In particular the question of home care also seems to me to be a reasonable one, but as I say above, I would defer entirely to the expertise of these two particular specialists in their areas.
- CONCLUSIONS
4.1Mr XXX has now reached a stage of medical finality. That is to say that he has made as much spontaneous recovery as he can and to further practical recovery in any of his disordered neurological functions, including bladder and mobility can be expected. The treatments that he has had to try to assist him from the Physiotherapists, Rehabilitation Services, Spinal Injury Services, Clinical Psychologists and the Pain Clinic are all perfectly reasonable and have produced benefit as can reasonably be expected. Mr XXX remains unemployed and in practical terms I believe him to be unemployable. He has genuine chronic pain, which interferes with his ability to concentrate properly, partly because of the presence of the pain itself and partly because of the large amount of medication, which he has to be on to keep this within management grounds. In practical terms, I do not believe that there is going to be any significant traumatic improvement in pain management, which will alter Mr XXX’s present state in the foreseeable future. I cannot conceive of any sort of work that he can be realistically expected to do because of the combination of physical inability to move, chronic pain, bladder and bowel disturbance and restricted travelling ability.
4.2He is dependent on his family for care, as has been set out in the Disability and Nursing Care reports. The condition he has is not one which will shorten his life expectancy providing he continues to carry out self-catheterisation in an approved fashion; intermittent self-catheterisation is not associated with shortened life expectancy, as long as it is carried out with appropriate sterile precautions and under supervision, as is the case here. He has had physiotherapy, particular from the point of view of hydrotherapy, which is reasonable. The question clearly arises as to whether or not he will require to continue with this; certainly I think it would be appropriate for a physiotherapist just to assess him once a year to ensure that he continues to carry out the exercises in an appropriate fashion. When patients have been doing these exercises for many years, it is quite easy for them to begin to do them slightly wrong and for this reason it is worthwhile having a physiotherapist just keeping an eye on people and making sure that they do not develop bad habits or shorten the exercise programmes that they have to carry out to try to keep them as mobile as possible. I do not believe that any more physiotherapy beyond that would be of benefit, but it would certainly be of benefit for him for example, to be able to go to a swimming pool on a regular basis, as this does help people with chronic pain to keep as mobile as possible.
4.3I would suggest that he try to lose weight; this is however a counsel of perfection and I think you have to be realistic that in patients such as Mr XXX who have previously been physically active and well, who are left with chronic pain, with restricted mobility and have to take large amounts of drugs, we cannot simply tell them to cut their food intake down to a point where they are only eating tiny amounts; I would agree that compassion has to be accepted and I do not think that although Mr XXX is making valiant efforts to reduce his weight, that in practical terms he is going to be able to control his weight in future beyond where he is now. Certainly he should not put weight on, but I think he is going to find it difficult in practical terms to reduce his weight any more than he already has. This is no criticism of Mr XXX because of this, but I do not think it would be a reasonable or compassionate suggestion that he should lose weight to try to improve his mobility. His mobility is not impaired because of his excessive weight, but because of the events that led to this legal action.
4.4There are no further investigations that I would advise other than to say that he should continue with his present medication indefinitely. He will need to remain under the supervision of the Pain Clinic and the Spinal Injury Clinic lifelong, but in practical terms I do not believe that there is going to be any great improvement in any of the treatments they will be able to offer him. I would be happy to discuss this further if you felt it of assistance.
I understand that my report and any oral evidence I may give in relation to my report is for the benefit of the Court and that my duty as an expert is to the Court and not to the party instructing me. I confirm that I have complied with my duty to the Court. I believe that the facts that I have stated in this report are true and that the opinions I have expressed are correct.
MR D A CAMPBELL, BSc MB ChB FRCS FRCS[Ed]
Consultant Neurosurgeon
