The PMFA Journal and Hamilton Fraser Cosmetic Insurance have teamed up to provide a series of articles that will give examples of claims that occur from different procedures.
Conclusion to the previous case
Last issue’s Medico-Legal Forum discussed a case of first degree burns following laser treatment. You can read the case in the magazine, or here.
The matter is still ongoing. The defence solicitors have suggested to make a very low offer to the patient to be rid of the matter as there is scarring present. However, if this is rejected then the solicitors will carry out further investigations into the current condition of the scarring. Reserves are currently £40,000.
The case in question
Polydioxanone (PDO) thread lifting is still a fairly new treatment in the UK aesthetic industry having been developed in Korea over five years ago. The treatment has grown in popularity as it is not technically complex and allows a patient to have minimal downtime post treatment which, by comparison to the traditional surgical face lift, is very attractive to patients. With the increase in procedures being carried out, it is inevitable that claims are now beginning to filter through. Generally speaking they are for dissatisfaction or because the threads are protruding post treatment. These can be easily resolved with a follow-up appointment and / or a refund. One particular claim that we received in the past 12 months was for permanent damage to the patient’s face . They underwent the treatment but afterwards complained of swelling, bruising, indentation, nerve damage and infection.
The patient was left with permanent indentations on both cheeks which now require fat grafting and until this can be done are being managed with dermal fillers. The patient is also alleging psychological damages for the affect it has had on their confidence, work and personal relationships and has been undergoing cognitive behavioural therapy since the treatment. There are two reasons why the treating doctor could be held liable as a result of this. The patient’s solicitor alleges that the technique used was poor and that the insured was insufficiently trained. Secondly, not all of the side-effects that the patient experienced were listed within the consent form that the patient signed.
1. Hamilton Fraser Cosmetic Insurance Claims 2017.
This case raises a number of concerns related to the introduction of new techniques that might have been trialled and developed in other countries. It is an unfortunate reality that complications in aesthetic practice seem to follow conferences where new techniques are described and demonstrated. The problem is that the people who demonstrate new techniques are those who have mastered them through trial and error, practice and experience. It must be exceedingly rare for any new technique to be developed that does not have a learning curve and unless a practitioner is aware of this there will be a temptation to return home and try out this “wonderful, simple and easy” new procedure.
The easier a technique appears to be, the more likely that the unwary will “give it a go” without taking adequate care to learn, observe and practice. It is unfortunate also that with some new products or devices there may be a financial incentive which drives some manufacturers to encourage practitioners to try a technique describing all of the advantages and not mentioning the potential risks and complications.
There is pressure for the new independent practitioner to get a foothold in the market and they can be very vulnerable to the subtle arts of coercive persuasion. If the practitioner then relays to the patient a very upbeat description of the procedure, emphasising the simplicity and effectiveness, the potential then arises for a very difficult management challenge if things do not turn out as planned.
Polydioxanone (PDO) thread ‘lifting’ is actually a technique whereby a meshwork of threads is created in the facial skin. The threads are absorbable, but in the process, stimulate an inflammatory response that induces new collagen formation and tightening of the skin. The simplicity of the concept belies the complexity of the biological response and the need to exercise caution regarding both the physiological and pathophysiological response but also the psychological response to treatment. I would be interested to know if those who are currently performing this technique in the UK adopt the test patch concept to ensure no untoward reaction or sensitivity to the polydioxanone. Polydioxanone is commonly referred to as PDS and is a slowly absorbing monofilament suture (PDS = pretty dam slow) and is commonly used in wound closure by surgeons from many specialties. It is regarded as relatively biocompatible with complication free use, as high as 95% in abdominal wound closure, but that still leaves a small number of patients who do not react well. Transfer that poor reaction to a patient in whom multiple threads have been introduced into the face and a letter from a solicitor will surely follow.
The take away message is that there are no techniques or procedures that are guaranteed to work in 100% of cases. New techniques must be treated with caution and whilst there is always the first case in any practitioner’s repertoire it is important to be honest with the client / patient. There is not a single practitioner in aesthetic practice who has not, or will not, experience a patient who develops a suboptimal result. But, thankfully, not all such patients will sue their practitioner. Dealing with complications and the unhappy patient is a test of the maturity and competence of the practitioner. Ensuring that you are appropriately trained and going through the consent process in rigorous detail creates a very solid foundation from which to develop a professional relationship which can survive both the good results and the less favourable outcomes. Such preventive measures will also reduce the risk of litigation and / or compensation that a patient may claim.
One final point is to consider the concept of the Duty of Candour in such instances. The spirit of this ‘Regulation 20’ promulgated by the Care Quality Commission (CQC) is noble, but unfortunately, we do not live in a noble world and so there is a tendency to practise defensive medicine. It is always better to put too many, rather than too few, potential risks and complications on the consent form. If that frightens a patient or client away do not begrudge the loss of fee. Happy patients are more important than a happy bank manager. To keep both happy requires skill, but also luck. That is something the CQC does not seem to understand.
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