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19th November 2017    
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Patient A presented to Dr. O with pain the in right leg and right ankle on 23rd May.

Nine years earlier patient A has sustained a fractured right tibia which was treated with an interlocking Targon nail to the right tibia.

Dr. O did an x-ray of the right tibia. This showed a united fracture of the mid 1/3 of the right tibia with a retained 1.m. tibial nail, with a tight isthmus and a “slightly bent” nail.

Dr. O told patient that the pain was due to the retained nail and suggested the nail be removed.

On 25th May, the operation was done at 1435hrs under Image Intensifier (I.I.) control after Dr. O sourced the instruments to remove the Targon nail Image Intensifier.

By 1650hrs, Dr. O has only managed to remove two inches of the nail and in the process, fractured the proximal tibia. He did not attempt to drive the nail back as “he has not obtained patient’s consent!”

The protruding tibial nail was covered with povidone dressings and patient was returned to the ward.

Dr. O only visited the patient on 26th May at 1930hrs and explained the failure of the operation and the iatrogenic fracture of the tibia.

Dr. O persuaded the patient to have another attempt for removal, failing which he will reinsert the nail.

On 27th May at 1650hrs, the operation was repeated. Dr. O failed to remove the nail and also failed to drive the nail back to its original position. He abandoned the operation at 1750rs.

On 28th May he visited the patient and explained the failure. He told the patient a special instrument, “a diamond burr” was required to extricate the nail. The medical centre did not have it.

Dr. O managed to locate the “diamond burr” at the General Hospital.

Dr. O made the necessary arrangement for the patient to be transferred to General Hospital on 30th May.

Throughout the patient’s ordeal no x-rays of the tibia were done to document the “stuck” nail and the iatrogenic fracture.

On 30th May patient transferred himself from General Hospital to another private hospital.

On 4th June, the patient had the nail successfully removed without the need of a “diamond burr”. The iatrogenic fracture was plated. The tibia was split at the “isthmus” where the nail was stuck to enable the nail’s easy removal.

On 11 December, the iatrogenic fracture was noted to be uniting well.


i) An Orthopaedic surgeon should be cautious when removing intra medullary nails which have been inserted two years or longer. A patient would have walked, jumped or jogged on that limb with a possibility of “bending the nail”, making removal difficult. All nails should ideally be removed after the fracture has united.

ii) Dr. O having noted the “bent nail”, did not properly prepare and plan the operation. He did not know what to do when he got “stucked”.
a) He did not call for a colleague’s help
b) “Splitting” the tibia is a known and taught procedure for “stuck” nails.
c) The “diamond burr” was the wrong instrument; an oscillating saw is all that is needed. This is definitely available in all orthopaedic units.
d) His indifference for 24 hours after each operation in attending to the patient on two failed occasions leaves much to be desired. The first consent form signed by the patient permitted Dr. O “consent to such further or alternative operative measures or treatment as may be found necessary during the operation”. There was no need for a “second consent’.
e) He was sued and the case was settled out of court without admission of liability.


A thirty year old male was involved in a motor vehicle accident on 4th June. He sustained:

i) open, comminuted fracture proximal left tibia and fibula
ii) closed fracture distal left radius
iii) deep laceration left ankle

He was admitted to a private medical centre at 12.40pm. He was assessed by the medical officer at the A&E department. The patient was told the operations will be performed at 7pm.

The operation did not start till 2am the next day. When patient queried at 8.30pm on the delay of the operation, the nurses informed that the operating theatre (O.T.) was being cleaned. By 11pm when the operation had not started the nurses told him that the O.T was used for another operation by another doctor.

The comminuted fracture of the left tibia was immobilized in an external fixator. The fractured distal left radius was reduced and immobilized in a plaster cast.

Postoperatively the attending orthopaedic surgeon explained the details of the operations. The check x-rays revealed that there was mal-alignment of the fracture of the left tibia and fibula. When questioned the orthopaedic surgeon’s reply was “it was meant to be that way”. When the patient questioned again whether it will affect his walking the orthopaedic surgeon answered, “it will not”.

Throughout the follow up the mal-alignment was not corrected.

On 1st Sept, the external fixator was removed. The patient alleged that the orthopaedic surgeon did not know how to remove the external fixator. He even asked the patient to remove the fixator! The patient retorted “you are the doctor!” The proper tools were not available. It was a very painful ordeal for the patient to have the fixator removed. The orthopaedic surgeon left in a huff and did not discuss the subsequent management.

On 6th Nov, the orthopaedic surgeon did not keep an appointment with the patient. Instead the patient was seen by his colleague who commented that the mal-alignment of the left tibia and fibula needs to be corrected otherwise the patient’s gait and ability to run will be affected.

The patient was so disillusioned that he sought surgical correction at another hospital.

The patient lodged a complaint against the hospital for the poor quality of service – nursing and orthopaedic management.

The orthopaedic surgeon was asked to respond to the delay in the operation, the mal-aligned left tibia and fibula, his inability to remove the external fixator and not keeping the appointment with the patient on 6th Nov. The orthopaedic surgeon chose not to respond to above queries!


1. Patient must be kept informed on the cause for the delay in any operation.
2. The duty of the surgeon is to liaise with O.T. on the urgency to surgically treat an open fracture as soon as possible, within six hours of injury.
3. In the private sector a second operating theatre should be opened to cater for a second emergency.
4. The mal-aligned tibia and fibula should have been corrected, the orthopaedic surgeon could have asked for help from a colleague.
5. It reflects badly on the orthopaedic surgeon if he fumbles to remove any device in a conscious patient. One must be prepared to have all the appropriate tools or instruments before doing a procedure.
6. The standard of care and duty of care of the orthopaedic surgeon falls below the accepted norm.

Mr. H had registered at Dr. C’s general practice clinic earlier as a patient. He requested for cough mixture.

One week later Mr. H turned up at the clinic to ask for repeat cough syrup. Dr. C was doing a procedure and his nurse dispensed the cough mixture. Immediately, four officials from the Pharmacy Department of the Ministry of Health accompanied by two policemen entered the clinic.

They took away 4300 dihydrocodine tablets, promethazine syrup, sugar syrup, empty bottles, poison register, codeine register and Mr. H’s medical record.

Dr. C has been giving codeine in syrup form for addicts for heroin withdrawal symptom. Dr. C feels that codeine is a drug that is not on Third Schedule (Section 30) – PSYCHOTROPIC SUBSTANCES.


1. Dr. C’s clinic has been under surveillance.
2. Mr. H was an agent provocateur.
3. Codeine is listed under the Third Schedule
4. He is storing a huge quantity of codeine. He cannot explain this.
5. Dr. C has violated his medical indemnity – MDM is not liable for “any claim directly or indirectly caused by or contributed to by any act in violation of any law or ordinance”.
6. Dr. C is welcomed to use MDM’s panel of solicitors at his own cost.
7. His nurse dispensed the codeine syrup without his prescribing – he was doing a procedure.


A general practitioner has been attending to a lady for antenatal follow-ups. On the last visit the patient complained of backache (bilateral loin pain) with frequency of micturition. She was treated for urinary tract infection.

The patient subsequently approached Dr. AA for a medical report “to assist her divorce application”.

Dr. AA enquired:-

i) Can she issue a medical report?
ii) Can she state that the backache was due to the husband’s assault?
iii) What should be the contents of the report?
iv) If the report is written and if she is asked to attend court hearing for the divorce application can she refuse to attend?


1. The patient has requested for a medical report. The doctor is duty bound to issue a report at a patient’s request.
2. Dr. AA recorded that the backache was due to a urinary tract infection. There is no record in the notes during her antenatal follow-ups that she was assaulted. Dr. AA cannot state that backache is due to the assault – she can be sued by the husband.
3. The contents of any medical report should be factual, stating the clinical findings, results of the investigations, diagnosis and any follow up arrangements. Do not give an opinion. The doctor can charge a fee for the medical report.
4. Dr. AA cannot refuse to attend court if she is asked to be a witness to verify the contents of the medical report she wrote.

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