Clinical failings DC case

RE: Clinical failings DC case

Chris Milligan — Sun, 22 Dec 2019 08:41:24 GMT

[quote userid="3169" url="~/001/nonclinical/f/life-in-practice-discussions/28753/clinical-failings-dc-case/218348"]Elephant in the room, if you look down the list of 2019 DC cases not many are UK grads.[/quote]

how did you come to this conclusion? it doesn't show where they graduated on the list of DC cases.

RE: Clinical failings DC case

Bob Russell — Fri, 20 Dec 2019 09:59:08 GMT

[quote user="Matt Hilary"]

I've been told it's ligation at the cervix rather than ovarian end that generally leads to ureteral ligation.

[/quote]

Hence the bilateral ligation! Makes sense.

There are plenty of smaller practices working quite safely. This was not a one man band.

Plenty of 'corporate' type practices function with a single vet (or less) on site.

Until recently this was a single vet practice. I accept it was extremely stressful at times and relentless but I always felt there was support available.

Specialists, VetSurgeon, even near by practices have provided an element of safety net. It is there but you have to make an effort.

There are some elements that concern me but the reality is this was poor surgery, poor follow up diagnosis, poor treatment.

I would lose a lot of sleep if it happened here!!

Would Metacam be contraindicated here? The damage to the kidneys would be a result of obstruction. I doubt meloxicam could have made the situation worse.

I was under the impression that misdiagnosis was not part of the RCVS remit? Misrepresentation and being untruthful are! Failure to care for the patient overnight come half way.

If this was my cat I would be after blood!!

RE: Clinical failings DC case

Matt Hilary — Fri, 20 Dec 2019 08:44:04 GMT

I've been told it's ligation at the cervix rather than ovarian end that generally leads to ureteral ligation.

RE: Clinical failings DC case

Neil Wheadon — Thu, 19 Dec 2019 22:52:33 GMT

[quote user="Kate Richardson"]I totally agree David. But what do you suggest we do? There surely has to be enough of us judging by the agrees to your post to ‘do something’?[/quote]

I feel that we should be looking at the circumstances within which vets who go through the process are working.

James Dunne commented that we are judged by ours peers and even though he was no longer sure this applies, I do and this is how I conduct myself.

However where are the peers?

Well years ago it was simpler. There was a large practice in every town with maybe the odd branch surgery which was no more than a lock up. Vets worked in convivial groups and had easy access to knowledgable and sympathetic peers.

Today the profession has changed. The vast majority of night clinics are sole charge (spate of RCVS cases last year) There are now many practices in many towns, each with a sole vet, not in name as such but with an increase in part time working a practice may have 3 vets on the books, but only one works at a time.

So any vet in a quandary has only a specialist to turn to, either through phone call or E mail and we need to be reasonable here, what specialist without seeing the case is not going to offer advanced advise, for that is their training.

Maybe I'm biased, as multivet practices don't use locums as much as smaller practices, but i feel if you dig into these cases you will find a pattern of sole working and little support.

The solution in my case is the VDS. I call them maybe once a year simply to see if what I am doing is reasonable. I feel that as a mutual and me shelling out £550 for the privilege that's OK.

Maybe the RCVS should look to employ a few generalists full time who are available to discuss a case, nip any issues in the bud, act as a sounding board. Prevention is better than having your name and reputation dragged through the press and all that goes with it. I'd do that job

Neil

RE: Clinical failings DC case

Kate Richardson — Thu, 19 Dec 2019 22:19:48 GMT

[quote user="David Mills"]

[quote user="James Dunne"]Notably, a board-certified specialist's view was the only clinical one accepted by RCVS. While I accept that this case involved an error because of very poor competence and was compounded by very poor professionalism, does anyone else find it a bit worrying that the goalposts have been shifted in the realm of clinical judgement?[/quote]

It has been shifting this way for a while, I feel, and it is simply mission creep from the traditional university teaching models most of us went through. Taught about GP medicine by specialists.

It is a multifaceted thing, but the one shift is the standardisation of approach by large veterinary groups that have specialists in their clinical standards groups. I posted on here a while ago about a cat bite abscess that the owner was gravely warned to have full bloods including blood gases before a sedation or GA. Some groups are now refusing to do GAs without preGA bloods.

Such changes are behind the referral culture for relatively simple ops. Few places in London perform orthopaedics these days, and there is usually a tame specialist within a group that are consulted on the most simple of xrays for the most simple of fractures. We see overtreatment every day. Pelvic fractures in cats now must be fixed surgically according to some in the ivory towers.

It started a few years ago with the nonsense notion of a 'minimum database' applied withiut reason or critical thinking, and has led us down the path of over treatment, and deskilling, and dissatisfaction.

What's behind this? I believe it is a reluctance from GPs to challenge the status quo and to demand evidence and justification from some key opinion leaders. That and the slow erosion of major bodies by representatives of large groups, including RCVS. And the continued fear instillation at some universities about graduates abilities and what they must not do. In most professions the referral procedures filter down into GP practice. In vet medicine it's the opposite. Things like PUs, TECAs, fractures, cruciates are disappearing from primary care needlessly.

Semi specialisation via certificates has also fallen victim to the curse of standard approach. There are ways of answering and unless you play the game you won't pass. What used to be a discussion of approaches between professionals has, in most cases, become a rerun of university vivas.

What to do about this? Possibly a pressure or lobby group from the area of veterinary medicine that >95% of UK vets are employed in. Ever wondered why there isn't a Society of GPs? BSAVA used to be more representative. But look at their Summit this December. Same old names, pontificating abiut a profession that they simply do not understand any more. At £500+. Nonsense.

There are exceptions within this. To name a few but not all, Malcolm Ness who used to be on here was one who had a very healthy disregard for the great and good and helped me on several occasions in an understanding way. Ian Ramsey is endlessly pragmatic and informative. There are others.

This is not specialist bashing in any way. But should a specialist be holding court on GP practice? If so, do GPs get a say in referral practice? It's completely unbalanced. It's erosive. And it is damned fucking patronising.

[/quote]

I totally agree David. But what do you suggest we do? There surely has to be enough of us judging by the agrees to your post to ‘do something’?

RE: Clinical failings DC case

Dinu Catilina — Thu, 19 Dec 2019 21:38:32 GMT

[quote user="Michael Woodhouse"]

Elephant in the room, if you look down the list of 2019 DC cases not many are UK grads.

[/quote]

True but maybe we should collate the last 10 years of data before drawing conclusions? If what you suggest is true that overseas vets (well you probably think east europeans as I'm sure you wouldn't include NZ and Au) are more likely to not obey the code of conduct, I wonder why?

My speculations:

1. Many are not prepared for general practice and are treated as fully qualified competent vets and not like a new grad

2. Some feel pushed to do things outside their area of competence and are afraid to say no.

3. Some don't understand the true implications of not following the code

4. Rules are rather fluctuant in other countries and there is no change in mentality on arriving here

5. The fear of RCVS is numbing and can push someone in doing stupid things

6. Non british vets are more likely to be complained against and less likely to receive support

RE: Clinical failings DC case

James Dunne — Thu, 19 Dec 2019 21:27:49 GMT

[quote user="vs0u "]

[quote user="James Dunne"]Mike Jessop [I think of VDS?] made a remark regarding blood testing an animal that wasn't eating the day after a spay, to indicate that likely a large body of veterinary surgeons wouldn't go straight for a blood test[/quote]

Not sure this is correct - according to the document, the cat was 3 days post spay, hadn't been eating, hadn't passed urine or faeces, and had been vomiting. I think most of us would be thinking about renal failure as a possibility regardless of any surgical mistakes. Also, the owner had requested bloods.

[/quote] I may have gotten the timeline wrong. I am not trying to suggest that bloods weren't indicated or to exonerate the guilty parties, who both thoroughly deserved their sanctions. I am merely pointing out the manner in which the logic for peer comparison was dismissed by RCVS. This is worrying; maybe I'm reading things out of context or too much between the lines, but we should be concerned by it.

RE: Clinical failings DC case

vs0u — Thu, 19 Dec 2019 20:29:05 GMT

RE: Clinical failings DC case

David Mills — Thu, 19 Dec 2019 19:34:38 GMT

It has been shifting this way for a while, I feel, and it is simply mission creep from the traditional university teaching models most of us went through. Taught about GP medicine by specialists.

RE: Clinical failings DC case

Sammy82 — Thu, 19 Dec 2019 19:11:30 GMT

[quote user="Bob Russell"]

How easy is it to ligate ureters? Have to admit it has never occured to me that you could so it is a genuine question.

[/quote]

I was wondering the same. Occasionally reading about it happening makes be a little paranoid. But as previously said, if you visualize the ovary (ovarian pouch) properly and make sure you clamp nothing but the pedicle, is there still a potential risk?

RE: Clinical failings DC case

James Dunne — Thu, 19 Dec 2019 19:07:18 GMT

There is a much worse elephant in the room than the nationality of the vets [of course there may be a trend towards poor competence, but clients are possibly more likely to complain about non-nationals than nationals, which may skew the trend]. I've read the whole thing and while this was a total and utter inexcusable cluster**** from start to finish, compounded by dishonesty, the RCVS also made a pronouncement that should make anyone shiver. Mike Jessop [I think of VDS?] made a remark regarding blood testing an animal that wasn't eating the day after a spay, to indicate that likely a large body of veterinary surgeons wouldn't go straight for a blood test, only to be told by RCVS that this line of thinking was irrelevant. In times gone by, you'd be judged against what would be considered acceptable by a body of your peers - this is no longer the case it would seem. Notably, a board-certified specialist's view was the only clinical one accepted by RCVS. While I accept that this case involved an error because of very poor competence and was compounded by very poor professionalism, does anyone else find it a bit worrying that the goalposts have been shifted in the realm of clinical judgement?

RE: Clinical failings DC case

Michael Woodhouse — Thu, 19 Dec 2019 18:51:10 GMT

Elephant in the room, if you look down the list of 2019 DC cases not many are UK grads.

This sounds like a right royal *** up.

RE: Clinical failings DC case

Sarah Keir — Thu, 19 Dec 2019 17:10:36 GMT

I would also say possible but not very likely in a competent surgeon. I have picked up ureters but never clamped or ligated.

I was taught to check you have the ovary and the uterine bifurcation on the tubey bit you have before clamping or ligating, whether dog or cat. And then check have both ovaries in entirety before closing the abdomen. Three times to realise it did not fit the pattern before irreparable damage. Did the surgeon not realise there were no ovaries? Or was it supposed to be an ovary sparing spay?

RE: Clinical failings DC case

Lucy Fleming — Thu, 19 Dec 2019 16:11:29 GMT

[quote user="Bob Russell"]How easy is it to ligate ureters? Have to admit it has never occured to me that you could so it is a genuine question.[/quote]

I remember having the fear of it drummed into me in vet school (to the point that I still have an occasional mild panic if I encounter a tough round ligament, over 10 years out), but not actually that easy, I would say. However, it must be fairly possible.

RE: Clinical failings DC case

Bob Russell — Thu, 19 Dec 2019 15:38:43 GMT

The offer of referral is probably obligatory in cases such as this. Practices carry insurance to cover this sort of cost as a requirement of registration.

Surgical cock up followed by a chapter of disasters and mismanagement. However tough it may seem, being honest with clients is essential.

How easy is it to ligate ureters? Have to admit it has never occured to me that you could so it is a genuine question.

RE: Clinical failings DC case

Gillian Mostyn — Thu, 19 Dec 2019 14:05:52 GMT

In this case bilateral ureteral ligation would need a very specialist soft tissue surgeon, and is still likely to be unsuccessful. Referral is obligatory.

This is the first DC case I've seen where I think the vets were possibly treated too kindly. Somebody made a serious surgical error....it happens. But they then allowed that animal to suffer for what must been a dreadful 5 days before it died to hide that error. (Either that or they truly are incompetent ...should have been spectacularly obvious this kitten was seriously ill). I hope they are very sorry indeed.

RE: Clinical failings DC case

Lucy Fleming — Thu, 19 Dec 2019 12:03:48 GMT

I think this is a little different to most other cases where whether or not to offer referral could be argued to be a grey area. It seems that this case was one of possible ureteral ligation during a spay, which is a recognised possible complication, but certainly a serious surgical error. I could be wrong here, but I seem to recall VDS advice regarding this situation be to certainly seek specialist advice as a minimum, in order to get the best chance of a reasonable outcome.

I would imagine that possibly fear of the possible consequences sent the clinicians involved into a bit of a tailspin, and ultimately made the outcome worse for them (not to mention the cat, though the outcome may have been the same in the end)