Insights
Case studies are an excellent way of showing our experience in action and demonstrating how we can make a difference.
Case Study One - The following is a summary of the key issues relating to a clinical negligence claim in which Michael Burrell, Director of Marston Wellbeing, acted for a mother who was originally from West Africa. The events serve as a useful example of common issues which arise for both the service user and the clinicians in relation to medical treatment for people from ethnic minority backgrounds.
The Detail
Case Study One
The Background
At her booking appointment, Michael’s client [Mrs P] was assessed by her consultant obstetrician as being at high risk during labour and so not for induction.
On her due date, Mrs P attended hospital with decreased fetal movements and was kept in overnight. She was examined the following day by the consultant; he recommended that a C-section take place that day.
Whilst awaiting the procedure, Mrs P spoke to speak to a midwife who was also originally from West Africa. The midwife advised Mrs P that a C-section was not a good idea. This is because, culturally, it would be preferably to have a vaginal birth as opposed to a C-section. The midwife told Mrs P that if she underwent a C-Section, she could be paralysed. Mrs P told her consultant she was too frighted to have a C-section. The consultant did not wish to be seen to be pressurising his patient; he did not seek to understand why Mrs P had changed her mind. As a result, Mrs P did not proceed with the C-section.
Despite the booking consultant’s instructions that Mrs P was not for induction of labour, following the abandoned C-Section, the plan was then for Mrs P to be induced at Term + 5.
Mrs P arrived at the delivery suite at Term + 5. Mrs P wanted to wait for spontaneous labour. She also asked about a C-section: in essence, she wasn’t sure what she wanted, which was frustrating for the doctors. This kind of uncertainty and indecision is not uncommon in Mrs P’s culture in stressful and unfamiliar situations: there is a tendency to step back and not engage. The clinical team were not aware of this, finding instead Mrs P’s responses to be contradictory and frustrating. The doctors, following an artificial rupture of membranes, proceeded with Syntocinon in order to induce labour.
The Syntocinon caused Mrs P’s uterus to rupture. She was rushed for a Category 1 (emergency) C-section. Tragically, by the time she was delivered, Mrs P’s daughter had been hypoxic for over half an hour and, as a result, she was born with hypoxic encephalopathy.
The Outcome
Mrs P’s daughter suffers from bilateral mixed spastic-dystonic cerebral palsy. She has no speech. She has severe learning difficulties. She has a 50% chance of developing epilepsy. She will require on-going medical treatment, including surgical intervention for hip dysplasia and Botox therapy for spasticity. She will require adapted accommodation and 24-hour care for life.
This tragedy would have been avoided if the parties involved, both Mrs P and her treating clinicians, had a better understanding of one another. The cost of the litigation, including damages and legal fees, will exceed £20,000,000. The birth injuries were entirely avoidable. They arose because of a disconnect between the clinicians and the patient regarding her understanding of, and the cultural implications in relation to, the proposed treatment.
Key Areas Of Miscommunication
- The initial advice, that Mrs P was not for induction of labour, was not explained to Mrs P in medical and cultural terms that could be easily understood. There was no acknowledgement by the consultant that Mrs P may have limited understanding of the potential consequences of the treatment options nor that medical necessity had to be balanced against cultural views on the proposals. As such, it was assumed Mrs P would accept the consultant’s advice; it wasn’t envisaged that cultural demands would weigh heavily in Mrs P’s decision-making process.
- When Mrs P decided not to have the C-section planned for that day, the consultant did not explore why she had changed her mind. The consultant could have asked Mrs P what she may have heard regarding the proposed surgery that was frightening her. Time spent explaining the risks and benifits of the different options is likely to have resulted in a better outcome.
- On the day of delivery, Mrs P withdrew from the discussion because it was a stressful and unfamiliar situation. This is culturally typical. As such, her consultants found her to be awkward and non-compliant. They pressed ahead with treatment Mrs P did not wish to engage with.
Case Study Two - The following is a summary of the key issues relating to a clinical negligence claim in which Michael Burrell and Suad Duale, Directors of Marston Wellbeing, assisted a Ugandan who was suffering from mental health issues.
The Detail
Case Study Two
The Background
Mr D grew up in Uganda. He was exposed to many terrible events during his childhood and went on to suffer Post Traumatic Stress Disorder and chronic depression. He didn’t received any treatment for his mental health issues whilst living in Uganda. After moving to the UK, he sought treatment from his GP in relation to the symptoms of depression and PTSD.
Mr D presented with insomnia and irritability but denied low mood. Although he was experiencing quite significant and debilitating flashbacks in relation to the events he witnessed in Uganda, he was unable to express these sytoms to his GP. Mr D was diagnosed with high blood pressure and insomnia. This continued for a number of years.
Mr D denied depression because, culturally, it was unacceptable to admit low mood. In his culture there is a huge stigma about mental illness and a belief that if you are “caught being mentally ill” then your children may be removed. Mr D’s GP was unaware of this and so did not seek ways ressure Mr D that the consultations were confidential or that depression is quite a common condition.
In addition, in Mr D’s culture, it is not possible to differntiate between a flashback and merely thinking about something. As a result, Mr D’s GP had no indication that Mr D may be suffering from PTSD. The diagnosis and treatment of mental health issues in the UK is based entirely on western concepts and, as such, accurate diagnosis in relation to ethnic minority service users can be problematic. Even when the correct diagnosis is reached, treatment will often be ineffectual unless the service user understands what the treatment is and why it is being prescribed.
The Outcome
As a result of Mr D’s cultural sensitives with regards mental health issues, his mental health problems went undiagnosed for many years whereupon they had become chronic and more refractory treatment.
Michael and Saud worked with a Mr D and a psychiatrist in order to arrive at the correct diagnosis. The psychiatrist found that:
- There are particular challenges in helping Mr D because of the cultural context;
- It is likely that when Mr D was presenting to the GP with insomnia, yet denying depression, he was probably depressed but it was culturally unacceptable to admit to low mood. Unfortunately, this means treatment was delayed and his symptoms continued to worsen;
- There are some difficulties in translating various concepts into different languages. For example, in Mr D’s culture, it is almost impossible to differentiate the idea of flashback from merely thinking about something. This made arriving at a diagnosis of PTSD very challenging; and
- Mr D said that for a long time he tried to hide the effects of his depression. He said he was very low in mood but denied it to everybody, including his GP, because he was fearful of what that would mean. In his culture there is a huge stigma about mental illness and a belief that if you are “caught being mentally ill” then your children may be removed.
Mr D’s mental health issues will now require consultant input, as well as that of a CPN and a psychotherapist. Had his mental health issues been identified timeously, they are likely to have resolved with antidepressants and CBT / EMDR arranged via his GP. This would have avoided the significant secondary care costs and also saved the GP time and effort whilst they were incorrectly treating Mr D for insomnia and high blood pressure
Key Areas Of Miscommunication
- Mr D felt very depressed and was suffering from PTSD following the traumatic events he witnessed before moving to the UK. He did not know what was wrong with him and so did not seek medical treatment on arrival in the UK. This is one of the factors which prevented early identification and treatment of his mental health issues.
- Mr D hid his mental health symptoms from her GP because he was concerned regarding the cultural stigma relating to mental health issues. His GP was unaware of this and as such did not arrive at the correct diagnosis.
- Mr D’s GP was not aware that some of the common medical terms we use in the UK may not be understood in other cultures. This can create a diagnostic lucuna which is hard to bridge.
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