Hospital not liable for infection of replacement knee joint
A recent legal case involving clinical negligence allegations by a patient who had undergone complete knee replacement.
In the case of Oukhellou v Luton and Dunstable Hospital NHS Foundation Trust  EWHC 2303 (QB), Ahmed Oukhellou, the claimant, had been diagnosed with osteoarthritis and underwent a total knee replacement operation on 1 April 2008. After being discharged from hospital on 7 April, he received care from community nurses and on 24 April saw the operating surgeon for an outpatient review. The surgeon’s registrar carried out another review on 4 June, but did not advise any further treatment.
On 12 June the claimant was taken by ambulance to hospital because he had developed an acute bacterial infection of the replacement knee joint. At this stage the infection was treated with antibiotics and by being washed out, and it was also discovered that a surgical instrument called a trocar sheath had been left inside the joint. Revision surgery was performed later on 16 October to remove the infected joint and replace it with a new prosthesis.
The claimant argued that the registrar’s review on 4 June had been entirely cursory and that, contrary to his note, the knee was swollen, red and hot. It was alleged that the registrar should have admitted the claimant to hospital immediately in order to explore the wound and take samples for culture. If that had been done, a course of antibiotics and a surgical debridement (removal of infected tissue from a wound) would have treated the infection and avoided the revision surgery.
Denying liability, the defendant NHS Trust submitted that the claimant did not have an infection on 4 June. There was no evidence which would have led a reasonably competent surgical registrar to admit the claimant for invasive procedures and it had not been a breach of duty simply to keep him under review.
The High Court found that the claimant’s recollection of events was unreliable and it preferred the written medical evidence. Accordingly, the state of the claimant’s knee on 4 June was as recorded in the registrar’s clinical letter. There was no sign of infection and the wound was healing well, except for the distal part where a stitch had been removed and a small opening caused by a suture reaction which had been treated. Antibiotics would therefore not have been a suitable treatment at this time and it was not necessary for the registrar to take a wound swab or any blood samples.
If the claimant had been admitted to have the wound explored surgically, certain dangers would have been involved and his claim was brought with a significant element of hindsight. Applying the test in Bolam v Friern Hospital Management Committee  1 WLR 583, the registrar had not fallen below the standard of care to be expected from a reasonably competent orthopaedic surgeon. It was not negligent to take a more conservative approach as there were risks attached to surgical intervention and no clinical signs that indicated a need to take such steps. In any event, the most probable route of infection was through the bloodstream rather than the open wound.
Although the defendant admitted that it was a breach of duty to leave the trocar sheath in the wound, the claimant did not suffer any pain or consequential loss. The wound had to be opened anyway when the infection took hold and the trocar sheath was removed during this procedure.
The claim was dismissed.
This article was first published in Claims Magazine