Brain, Vol. 123, No. 10, 2179-2180,
October 2000
© 2000 Oxford University Press
Book reviews |
MEDICAL NEGLIGENCE – THE CRANIUM, SPINE AND NERVOUS SYSTEM.
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The Radcliffe Infirmary, Woodstock Road, Oxford, UK
There can be few clinicians so sanguine as not to fear the occasional prospect of litigation. A busy neurologist will see, or be responsible for, perhaps 30 new patients a week. The clinical diagnosis may be inaccurate or the management less than optimal in 5% of cases. At least 75 patients a year may be less than delighted by their treatment. Over the years the figure is cumulative. After 10–15 years in clinical practice there will be 1000 such patients, some of whom will be potentially litigious. The further worrying aspect is that we may not be aware of the potential problem until we receive a letter sent by their lawyer months or even years later.
There are the added more acute anxieties in the hours following an outpatient clinic, perhaps whilst driving home. That elderly lady with very non-specific headaches and non-tender scalp arteries. Surely in retrospect an ESR should have been requested. That young man with severe exertional headache. Perhaps on reflection it was a sentinel bleed. The young woman with severe intermittent headaches that was reassured. Did not a colleague present a patient with a colloid cyst of the third ventricle with an almost identical history in last week's clinical round?
Oddly, the cases that cause anxiety and worry due to delayed diagnosis or stormy side effects to treatment rarely come to litigation and, paradoxically, the patients are frequently grateful. It is the others that, at the time, we feel we have managed adequately who may spring the surprises.
It is enough to turn one's mind to early retirement or, less drastically, scrutiny of this new publication. First, a word of warning. The book is not primarily targeted at clinical neurologists and neurosurgeons. The note on the dust jacket makes this clear: `The book will be of particular use to lawyers practising in the field of medical negligence as well as to hospital managers and of their risk-assessment units.' Somewhat as an afterthought it concludes: `neurologists and neurosurgeons in their clinical practice, and when acting as expert witnesses, will welcome the legal commentary.' The legal notes amount to only 50 pages in a text of over 300 pages.
In the Introduction, written by the editors John Garfield and Christopher Earl, the final paragraph suggests that the text is for those doctors—`generalists'—whose work includes disorders of the nervous system. It is certainly true that a general practitioner would benefit from reading the chapter on `General practice', and a general radiologist benefit from the chapter on `Neuroradiology', but would such readers purchase the text for a single chapter?
The chapters cover the entire field of clinical neurosciences and all are well written by distinguished experts in their own clinical fields. These include head injury, the cervical, thoracic and lumbar spine, spinal tumours, CNS infection, peripheral nerve lesions, paediatric neurology, hydracephalus and spina bifida, subarachnoid haemorrhage, brain tumours and epilepsy. Other chapters cover neurological disability, general practice, neuroradiology and psychosurgery. There is no consensus on references. `Neuroradiology' contains 42, whereas the following chapter on epilepsy has none. John Garfield and Christopher Earl personally contribute to over half the chapters. The chapter on `Avoiding litigation' (Garfield) catches the eye, but contains those truisms that are unarguable but difficult to know whether they would influence a reader's personal practice. It is of course evident in retrospect that deafness was due to an acoustic schwannoma and not wax and that dysuria was due to a cord lesion rather than prostatism. Symptoms can be vague and overshadowed by misleading non-neurological aspects in any individual case. It is simpler for the expert, with hindsight, to see when and how an error is made.
Certainly the content of most of the text supposes the reader to have general medical knowledge but no specialist training in neurology or neurosurgery. I feel it unlikely therefore that it will be easily understood by lawyers, and the danger is that the book will fall between two stools of not being directly relevant to either lawyers or neurospecialists.
The opening chapter on `The law' by Adrian Whitfield QC is particularly rewarding. There is a section on consent and clarification about breach of duty including discussion of the Bolam defence. Later sections cover causation and damages. Finally, there is explanation of the role and duties of the doctor as expert witness, including court procedure. At the end of seven of the chapters M. A. N. S. Leigh, a solicitor at Hempsons, writes a lively, relevant legal discussion. It is not clear why he has contributed to some chapters and not others. The legal contributions are without doubt the most relevant to neurologists and neurosurgeons.
There is still, I feel, room for a further text on this subject, more sharply focused for specialist readers. Numerous examples of both defended and undefended cases could be detailed with more extensive legal commentary and relevant contributions from medical experts. However, whether such a text would make good bedtime reading or simply induce acute anxiety is a moot point.
Adrian Whitfield should have the final word. He discusses the feasibility of `no win, no fee' cases, the role of a court-appointed expert and the improvement in pre-trial meetings when experts would be more flexible with respect to other experts' opinions. `Such an attitude must, in the long run, be of advantage to everyone concerned in litigation except (and, quite rightly, nobody minds about this) the lawyers.'
Notes
Edited by John Garfield and Christopher Earl.1999. Oxford: Blackwell Science Ltd. Price £57.50. Pp. 350. ISBN 0-632-05183-3.
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