To establish the incidence of litigation in Cauda Equina Syndrome (CES) and the causes of litigation. Review of 10 years of abbreviated records of the National Health Service litigation authority (NHSLA) (1997-2007) and eight years of medical negligence cases (MNC) reported on by the two senior authors (2000-2008). Patients who experienced CES and litigated. There were 117 patients in the NHSLA records and 23 patients in the MNC group. Review of timing of onset, delay in diagnosis, responsible specialist, place, and resulting symptoms. NHSLA cases. 62/117 cases were closed. The responsible specialists were as follows. Orthopaedic. 60. Accident and Emergency. 32. Other. 25. The commonest failure was delay in diagnosis, and the commonest complications were “neurological”, bladder and bowel. MNC cases. F:M;17/6. L4/5 13 cases, L5/S1 9 cases. The responsible specialist was orthopaedic (7), other (7) and in 8 cases the opinion was that there was no case to answer. Delay to treatment averaged 6.14 days. 18/23 patients described bowel and bladder symptoms, the information was not available in the remainder. Litigation is major problem in CES. In most cases orthopaedic surgeons are litigated against, and bowel and bladder symptoms remain the most disturbing cause of litigation. These surgeons are mostly not spinal specialists. In most successful cases of litigation there is considerable delay in diagnosis and management. Where there is incomplete Cauda Equina Syndrome urgent or emergency investigation and treatment is mandatory

Aim. The aim of this study is to evaluate the causes of litigation in spinal surgery and to identify preventable causes. Methods. Retrospective analysis of all claim data made available under Freedom of information act from NHS Litigation Authority between years 2000 to 2010. Results. A total of 581 (331 Orthopaedics and 250 Neurosurgery) claims were filed in England and Wales, of these 543 cases were settled while 38 cases were pending. 371 (69%) of 543 settled resulted in payout but 172 (31%) claims were successfully defended by the NHSLA. Average payout was £63,573 total £ 36935933 maximum payout of £ 1800000). This figure rose to average of £ 95125, (Total £553627720) when defence and claimant costs were included. The allegations categories were 123 failure or delay in diagnosis, 108 intra operative problems, 90 failure or delay in treatment, 45 suboptimal consent and in 40 failure to recognise complications. The successful litigations were result of neurological injury in 143, un necessary operation in 37, avoidable pain in 29, death 15 and Misc 31. Conclusion. Litigation can in part be attributed to the “no win no fee” culture; steps that can be taken to reduce the number of successful claims. Failure or delay in diagnosis and Intra operative problems can partially be attributed to lack of resources and or expertise emphasising the need for spinal surgery to be concentrated in specialist centres. Documented informed consent can also potentially decrease litigation. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Foot and ankle surgery is a rapidly evolving specialty. As the number and complexity of cases increases, the number of complaints, litigation and pay-outs has also risen. We aim to assess any learning points discerned from NHS litigation data to allow us help improve patient care. All claims made to the NHS Litigation Authority between 2007 and 2012 relating to foot and ankle problems were obtained under the Freedom of Information Act. These were reviewed, coded and split into subgroups to allow analysis. There were 232 successful litigation cases between 2007 and 2012. The total amount paid out was almost £18.5 million (range £112 to £1.6 million). A significant number of successful cases were due to patients not having full, informed consent. A large amount of money is spent in the NHS is spent on litigation. The amount of litigation and payout in foot and ankle surgery compares favourably with hip and knee surgery. Lack of informed consent is an easily reversible problem that should be decreasing but is actually on the rise. In our trust, we advocate the use of consent clinics which provide a robust and patient-centred approach to informed consent in foot and ankle surgery

Background: Over 70,000 hip replacements were performed in England and Wales in 2006/7 during which all litigation claims cost the National Health Service (NHS) over £600 million. Joint arthroplasty surgeons are twice as likely to be subject to litigation claims compared to other physicians. The complications associated with primary hip arthroplasty (HA) are well documented, however those instigating litigation in the UK are not known. In this study, the trends in litigation over the past 5 years were assessed to indentify the instigating factors and their associated success to highlight areas for further improvement in patient information and surgical management. Methods: Data from the NHS Litigation Authority on claims following HA unrelated to trauma between 2002 and 2007 were obtained and analysed. Results: 352 claims were made, 271 (77%) were settled of which 109 (40.1%) resulted in a successful claim. The total cost to the NHS was £8,558,000. The number of claims has increased from 54 in 2002 to 83 in 2007, while the rate of successful claims decreased from 46.7% to 12.9%. The three most common instigating factors were nerve injury (19.6%), Operator Error (14.2%) and ongoing pain (13.6%). The factors with greatest successful claims were Non-operative site injuries (70%), Operator Error (66%), Fracture (52.4%). Conclusion: Litigation claims following Hip Arthroplasty are increasing, although there rate of success is decreasing. Non-operative site injuries, operator error and fractures are predictors of a successful claim. However, failure to consent adequately, adhere to policies and standard practice can result in a successful claim. Protecting patients intra-operatively and maintaining high technical expertise while implementing policies and informed consent decreases the litigation burden to the NHS

A 5 year review of factors instigating malpractice claims and likely to result in a payout. Possible lessons for the future. Background. During 2002-2007 over 300,000 patients underwent knee arthroplasty (KA) in England and Wales, from which 204 cases of litigation were processed costing in excess of £5million. The complications associated with primary KA are well documented, however those instigating litigation in the UK are not known. This study assessed trends in litigation over the past 5 years identifying instigating factors and success rates to highlight areas for further improvement in patient information and surgical management. Methods. Data from the NHS Litigation Authority on claims following KA unrelated to trauma between 2002 and 2007 were obtained and analysed. Results. 246 claims were made, 171 (70%) were settled of which 81 (47%) resulted in a successful claim. The total cost to the NHS was £5,257,228. The number of claims has increased from 26 in 2002 to 67 in 2007, while the rate of successful claims decreased from 58% to 9%. The three most common instigating factors were ongoing pain(24%), operator error(23%) and infection(10%). The factors with greatest successful claims were operator error(80%), vascular injuries(75%), failure of post-operative care(55%). Conclusion. Litigation claims following KA are increasing, although there rate of success is decreasing. Operator error, vascular injuries and failure of post-operative care are predictors of a successful claim. However failure to consent adequately, adhere to policies and standard practice can result in a successful claim. Protecting patients intra-operatively and maintaining high technical expertise while implementing policies and informed consent decreases the litigation burden to the NHS

Definitions and perceptions of good and poor outcome vary between patients and surgeons, and perceived inadequate outcome can lead to litigation. We investigated outcomes of litigation claims relating to non-union and deformity following lower limb long bone fractures from 1995 to 2010. The database of all 10456 claims related to Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Data was searched for “deformity, non-union and mal-union”, excluding spine, arthroplasty, foot and upper limb surgery. The type of complaint, whether defended or not, and costs was analysed. 241 claims met our criteria, 204 of which were closed, and 37 unsettled. Deformity/mal-union constituted 97, and non-union 143. Coronal/sagittal deformity cost £4.2 million, mean £45,487 (60% received compensation). Rotational mal-unions cost £1.6 million, mean £114,263 (87% received compensation). Non-union cost £5.3 million, mean £75,866 (60% received compensation). Mean legal fees for coronal/sagittal deformity was £18,772, rotational deformity £37,384, and non-union £24,680. The total cost of litigation was £12.2 million, with a mean of £59,597 per settled claim. The mean pay-out for all confirmed negligence/liability was £56,046 (£1,300–£500,000, median £21,500) per case. Non-union is an accepted complication following fracture surgery. However, this does not mitigate against non-union being seen as representing a poor standard of care. While it is unclear whether the payouts reflect a defensive culture or were due to avoidable errors, and notwithstanding the limitations of the database, we argue that failure of the index surgery should prompt a referral to a specialist centre. The cosmetic appearances of rotational malalignment results in higher compensation, reinforcing outward perception of outcome as being more important than harmful effects. We also note that the database sometimes contained conflicting and incomplete data, and make a case for standardisation of this component of the outcome process to allow for learning and reflection

BACKGROUND. From 1995 the cost of litigation to the National Health Service (NHS) from surgical procedures has been over 1.3 billion GBP. Spinal patients can present diagnostic challenges and the consequences of delayed diagnosis and surgical complications can be devastating. As a consequence these patients represent a high risk when surgeons seek to indemnify themselves. We therefore, aim to highlight the litigation patterns for these injuries within the United Kingdom. METHOD. Data was obtained from the NHS Litigation Authority from 2002 to 2010 which was analysed. RESULTS. Of the 236 claims, 144 were related to trauma or acute diagnostic issues and 92 from elective surgery. The total financial burden to the NHS came to 60.5 million GBP/72.5 million Euros. Of this sum 42.8 million GBP/51.3 million Euros were paid in damages, and the remaining 29% in legal costs. The financial costs were on average similar for trauma and elective cases. The most frequent cause of successful litigation for trauma were, missed fractures (41.7%), missed cauda equina (23.6%) and spinal infection (11.8%). The emergency department (43.8%), orthopaedic surgery (28.5%) and Medicine (13.9) bore the brunt of the claims. For elective surgery, Spinal Damage(19.8%), failure in Post-Operative Care (15.4%), Infection (11%) and Wrong Level Surgery, Cauda Equina and Surgical Failure at 9.9%. were likely to result in a successful claim, and the litigation burden was felt by the orthopaedic(60.4%), Neurosurgery(18.7%) and other surgical disciplines (11%). CONCLUSION. Acute spinal fractures, cord compression and infection should be considered in patients in the emergency department setting, with appropriate examination and investigations for uncertainty. A lack of awareness of at risk cases increases the likelihood of a pay-out and sums involved. For elective spinal surgery, a failure in the consenting process and the technical skill of the surgeon are likely to result in a pay-out. A failure to identify post-operative complications such as infection and thromboembolism are also indefensible. Protecting patients intra-operatively and maintaining high technical expertise and vigilance post-operative in an adequately consented patient may decrease litigation rates

Background. Surgical patients have cost the NHS 1.3 billion GBP from 1995. Spinal pathologies can present diagnostic challenges, and the consequences of delayed diagnosis or surgical complications can be devastating and so creating high indemnity costs. We aim to highlight the spinal associated litigation patterns within the United Kingdom. Method. Data was obtained from the NHS Litigation Authority from 2002 to 2010. Result. From 236 claims, 144 were related to trauma or acute diagnostic issues and 92 from elective surgery. The financial burden to the NHS came to 60.5 million GBP. Of this sum 42.8 million GBP were paid in damages, and the remaining 29% in legal costs. The financial costs were similar for trauma and elective cases. The most frequent cause of successful litigation for trauma were, missed fractures(41.7%), missed cauda equina(23.6%) and spinal infection(11.8%). The emergency department(43.8%), orthopaedic surgery(28.5%) and Medicine(13.9%) bore the brunt of the claims. For elective surgery, Spinal Damage(19.8%), failure in Post-Operative Care(15.4%), Infection(11%) and Wrong Level Surgery, Cauda Equina and Surgical Failure(9.9% each). were likely to result in a successful claim, and the litigation burden was felt by the orthopaedic(60.4%), Neurosurgery(18.7%) and other surgical disciplines(11%). Conclusion. Acute spinal fractures, cord compression and infection should be considered in patients in the emergency department setting, with appropriate examination and investigations for uncertainty. A lack of awareness of at risk cases increases the likelihood of a pay-out and sums involved. For elective spinal surgery, a failure in the consenting process and the technical skill of the surgeon are likely to result in a pay-out. A failure to identify post-operative complications such as infection and thromboembolism are also indefensible. Protecting patients intra-operatively and maintaining high technical expertise and vigilance post-operatively in an adequately consented patient may decrease litigation rates

Background. In the UK 70,000 knee arthroplasties are performed each year. Although outcomes from knee arthroplasties are usually excellent, they can nevertheless lead to negligence claims. The aim of this study was to establish the incidence, cost and cause of negligence claims arising from knee arthroplasties. Method. All claims made to the NHS Litigation Authority between 2003 and 2008, where the operation was knee arthroplasty, were included in this study. Data obtained from the NHS Litigation Authority were reviewed, coded and analysed. For negligence to have occurred, patients must have suffered harm as a result of substandard care. Hence the cause of negligence claims was analysed in terms of: (1) Substandard care and (2) Harm caused. Results. There were 326 claims over the five-year period, resulting in an incidence of 65 claims per year. Of the 326 claims, 246 have been closed with 80 remaining open. 40% of closed claims resulted in the payment of damages. The total cost of negligence claims over the period was £6.6 million. Substandard care commonly encountered in negligence claims was: surgical quality (56%), post-op care (23%), and infection control (8%). Harms commonly encountered in negligence claims were: additional/unnecessary operation (30%), pain (23%) and amputation (8%). Conclusion. There is a significant litigation burden associated with knee arthroplasties. The unexpected prominence of additional/unnecessary operation, pain and amputation in negligence claims emphasise the need for patients to be warned about these risks

This study assessed the effect of litigation on the long-term outcome and recovery of ankle inversion injuries. 167 patients from an accident and emergency database were contacted by telephone. Thirty participants were litigating and these candidates were randomly matched with 30 non-litigating patients with respect to mechanism of injury. Each group had 27 patients with ankle sprains because of falls/trips and 3 after road traffic accidents. Radiographs when available of each participant were examined and the degree of soft tissue swelling over the lateral malleolus was assessed. 76.6% of litigants reported incomplete recovery compared to 26.7% of non-litigants. The median period of sleep disturbance, swelling, limping and non-weight-bearing was 1.5 days, 2.0 weeks, 2.0 weeks and 1.0 weeks for the non-litigants. This compares to 3.5 days, 10.0 weeks, 8.0 weeks and 8.0 weeks for the litigants using the same variables (p< 0.0001 in all cases). Where ankle radiographs had been taken swelling was equal in each group (9.0mm over lateral malleolus (30% of litigants incorrectly suggested an ankle x-ray had been taken, when it had not)). The majority of litigants (65%) thought that physiotherapy would not be beneficial in rehabilitating their ankle (35% non-litigants). It appears that litigation has a negative effect on the outcome and recovery of ankle sprains

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England. The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action. A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed. The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465. Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims

We review all litigation brought against English Orthopaedic departments involving children under the age of 16 and attempt to highlight areas where they might be avoided. The NHSLA (the National Health Service Litigation Authority) is a special Health Authority responsible for handling negligence claims made against NHS bodies in England. In addition to dealing with claims when they arise, there is an active risk management programme to help raise standards of care in the NHS and hence reduce the number of incidents leading to claims. By analysing the claims data, we have had the opportunity to see trends for which Trusts have litigation brought against them, how much this costs the Health Service and most importantly how this information can aid in clinical practice. Between 1995 until 2005/06 there were 408 cases involving orthopaedics in England that had reached a conclusion. Of those considered in our study (341), by far the most common broad category for litigation is missed or delayed diagnosis of a condition 179 cases (57% of all litigation cases) with 44% (80 cases) of those being upper limb traumatic injuries. Humeral supracondylar fractures and elbow injuries constitute 24% (44 cases) of all missed diagnoses with each having an average total payout of £27,998. Missed or poorly managed developmental disorders of the hip (DDH or SUFE) also have large total payouts. Other common causes for litigation are intra-operative errors with poor results/complications for fixation of humeral supracondylar fractures again being the most common. Complications of plasters also represent 7.3% of all claims, all with high total payouts. In assessing these trends, we suggest highlighting the potential for error during training of juniors and taking extra care during clinical practice. There are also implications identified for the planned provision of Orthopaedic care of children

Study design: A prospective study of 135 subjects with whiplash injury. Objectives: To identify factors predictive of prolonged disability following whiplash injury. Summary of background data: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision. Methods: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bivariate and multivariate analyses were undertaken to measure the association between putative risk factors and measures of outcome. Results: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p< 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome. Conclusions: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation

STUDY DESIGN: A prospective study of 135 subjects with whiplash injury. OBJECTIVES: To identify factors predictive of prolonged disability following whiplash injury. SUMMARY OF BACKGROUND DATA: Although subjects with whiplash associated disorders lack demonstrable physical injury, many exhibit prolonged disability. Disability appears unrelated to the severity of the collision. METHODS: 147 subjects with recent whiplash injury were interviewed for putative risk factors for disability. 135 were re-interviewed 12 months later to assess degree of duration of disability. Bi-variate and multi-variate analyses were undertaken to measure the association between putative risk factors and measures of outcome. RESULTS: The bodily pain score and role emotional scores of the SF-36 health questionnaire showed a consistent significant positive association with better outcomes. After adjustment for bodily pain score and role emotional scores, consulting a lawyer was associated with less improvement in NPOS (p< 0.01) after one year, but there was no significant association with rate of return to work. The degree of damage to the vehicle was not a predictor of outcome. CONCLUSIONS: SF-36 scores for bodily pain and role emotional are useful means of identifying subjects at risk of prolonged disability. The findings support the implementation of an insurance system designed to minimise litigation

The aim of this study was to review the data held with the NHSLA database over the last 10 years for negligence in spine surgery with particular focus on why patients ‘claim’ and what is the likely outcome.

Anonymous retrospective review

We contacted the NHSLA and asked them to provide all data held on their database under the search terms ‘spine surgery or spine surgeon.’

An excel sheet was provided, and this was then studied for reason of ‘claim’, whether the claim was open/closed and outcome.

A total of 67 claims of negligence were made against spinal surgeries during this time (2000-09). The number of claims had increased over the last few years: 2000-03, n= 8, 2004-06, n= 46. The lumbar spine remains the most common area (Lumbar: 55/67, Thoracic : 6/67, Cervical 6/67). Documented reasons for claims were post-operative complications (n= 28; 42%), delayed/failure to diagnose (n=24; 36%), discontent with preoperative assessment including consent (n=2; 3%), intra-operative complications (n= 10; 15%) and anaesthesia complication (n=3; 4%).

Twenty were closed and 47 remained open. The number of successful claims was 8/20 (40%). The mean compensation paid out was £33,409 (range was £820.5 to £60,693).

The number of claims brought against spinal surgeries is on the increase, with the most common area being the lumbar spine which perhaps is not surprising as this is the most common area of spinal surgery. Common reasons are post-operative complications and delay/failure to diagnose. The ‘success’ of these claims over the last 10 years was 8/20 (40%) with mean compensation paid out was £33,409.

Ethics approval: None;

Interest Statement: The lead author is the CEO and founder of a Personal Injury/Medico-Legal company

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122