Mr Q was admitted to hospital with sudden worsening signs of heart failure. A peritoneal catheter (a catheter into the abdomen) was inserted, but during the procedure, the split sheath (which is used to insert the catheter) was inadvertently pushed inside the patient. It could not be retracted.
A CT scan did not locate it, but ultrasound suggested that it was within the inner layer of skin. The decision was taken to operate to remove it. His therapeutic warfarin medication was discontinued, and not adequately substituted during his long wait for surgery. The operation itself did not locate the sheath and was abandoned. Mr Q suffered a stroke later that week. He remained in hospital for a number of months before discharge home, where he remained bedbound until death, around a year later.
Expert reports were obtained from a radiologist and a surgeon. The conclusion they reached was that it would be almost impossible to physically push the split sheath into a patient. The decision to operate was questionable, at best, given that the surgery was never going to locate an item believed to be in the inner layer of skin, and there was some question whether it could have not simply been left in situ anyway, posing no risk.
The fact that the sheath was never found suggests that it was more likely that rather than being inserted, it was removed prematurely and was never in fact pushed into the patient. There was therefore probably no need to have any surgery. There were then a further and inexplicable set of errors with the anticoagulant (medication such as warfarin, which are prescribed to prevent blood clots), linked to this event as they occurred whilst awaiting the surgery he did not need, but standing as breach in their own right.
A cardiologist confirmed breach and causation for the anticoagulation in its own right.
Defendant fully denied the case on all points. However, a settlement was reached with Mr Q receiving payment of damages.