A.Z. v Hannon (Approved)

Factual and Procedural Background

The Plaintiff, a married woman in her sixth decade with children, was granted a declaration of anonymity pursuant to section 27 of the Civil Law (Miscellaneous Provisions) Act 2008. The Defendant is a consultant general, colorectal and laparoscopic surgeon practicing at a private hospital in The City. The Plaintiff alleges serious personal injury, mental distress, loss, and damage resulting from negligence, breach of duty, and breach of contract by the Defendant in the provision of medical and surgical services. Specifically, the Plaintiff developed anal stenosis and a rectovaginal fistula causing severe pain, suffering, and psychological injury diagnosed as Post-Traumatic Stress Disorder (PTSD).

Initially presenting with haemorrhoids in May 2018, the Plaintiff underwent conservative treatment including pelvic floor physiotherapy and medication prescribed by the Defendant, which provided limited relief. After a detailed consultation, the Plaintiff elected to proceed with surgery and underwent an open haemorrhoidectomy in August 2018. Post-operatively, she suffered severe pain, bleeding, and difficulty passing motion. Follow-up examinations revealed oedema, spasm, and stenosis, leading to Botox injections and dilation procedures under general anaesthetic.

The Plaintiff lost confidence in the Defendant after a follow-up appointment was missed and subsequently sought treatment from another colorectal surgeon, who identified anal stenosis and a rectovaginal fistula. The fistula was treated surgically with a fistulotomy in March 2020, resulting in a satisfactory physical recovery. However, the Plaintiff continued to suffer severe pain, distress, and PTSD, supported by psychiatric evidence.

The Plaintiff’s personal injury summons alleged negligence and failure to exercise due skill, specifically criticizing the extent of tissue excision and the surgical technique leading to the complications. The Defendant denied negligence, asserting that the surgery was performed with due skill and diligence and that the complications were not caused by any breach of duty.

The case was heard over eight days, focusing primarily on factual issues of whether the complications were due to negligent surgery or unfortunate but competent treatment outcomes.

Legal Issues Presented

1. Whether the Defendant left adequate skin bridges during the haemorrhoidectomy to prevent anal stenosis.
2. Whether the Defendant’s surgical technique was negligent and caused a rectovaginal fistula through excessive or deep dissection or diathermy injury.
3. Whether the Plaintiff’s anal stenosis and fistula were caused by negligent surgical treatment or were unfortunate but recognized complications of competent surgery.

Arguments of the Parties

Plaintiff's Arguments

• The Plaintiff contended that the Defendant’s surgery was excessively radical, failing to preserve adequate skin bridges, which caused the stenosis.
• The fistula resulted from negligent surgical technique, likely due to a full thickness or deep diathermy burn to the rectovaginal septum or a partial thickness injury leading to necrosis and infection.
• The Plaintiff’s pre-existing overactive pelvic floor condition necessitated a more conservative surgical approach, which was not adopted.
• Alternative causes such as Crohn’s disease or injury from subsequent dilations were discounted.

Defendant's Arguments

• The Defendant denied negligence, asserting the surgery was performed with due skill, care, and diligence in a technically standard manner.
• The Defendant emphasized contemporaneous medical records showing adequate preservation of skin bridges and no evidence of deep injury to the rectovaginal septum.
• The Defendant argued that the Plaintiff’s pre-existing conditions, including pelvic floor dysfunction and anal spasm, were the likely cause of slow healing and stenosis.
• The fistula was more likely caused by subsequent mechanical dilatation procedures or infection, both without fault attributed to the Defendant.
• The Defendant disputed the timing and causation of the fistula, noting it would have manifested earlier if caused by the surgery.

Table of Precedents Cited

Court's Reasoning and Analysis

The court carefully reviewed the evidence from multiple medical experts, including independent consultants and the treating surgeons. It acknowledged that the Plaintiff undeniably suffered anal stenosis and a rectovaginal fistula following the haemorrhoidectomy. The central question was whether these complications were caused by negligent surgical care or were unfortunate but recognized risks of competent surgery.

Regarding stenosis, the court found that preservation of adequate skin bridges during haemorrhoidectomy is paramount to prevent stenosis. The Defendant’s surgical notes described adequate skin bridges, but the court accepted expert testimony that such notes are aspirational and that the adequacy of skin bridges cannot be reliably assessed shortly after surgery due to swelling and oedema. The court preferred the evidence of the Plaintiff’s expert, who opined that the stenosis was most likely caused by excessive excision of skin and tissue and inadequate skin bridges, particularly given the Plaintiff’s pre-existing conditions (perineal descent and overactive pelvic floor) which warranted a more conservative surgical approach. The Defendant failed to adapt the surgery accordingly and thus fell below the required standard of care.

On the issue of the fistula, the court found no evidence of a full thickness surgical injury but was persuaded that a partial thickness wound caused by excessive tissue removal or diathermy injury led to infection and subsequent fistula formation. The court rejected the Defendant’s argument that the fistula was caused by subsequent dilatation procedures or Crohn’s disease, finding these causes improbable based on expert evidence and timing of symptom onset. The court also accepted that fistulae can be difficult to detect early, explaining why it was not observed during earlier examinations under anaesthetic.

The court gave particular weight to the evidence of the Plaintiff’s treating surgeon, who successfully treated both complications and supported the Plaintiff’s case on causation. The Defendant’s reliance on statistical probabilities and post-operative observations was insufficient to rebut the Plaintiff’s evidence.

In sum, the court concluded that both the anal stenosis and fistula were caused by negligent surgical care falling below the standard expected of a consultant colorectal surgeon acting with ordinary care, as established in the cited precedents.

Holding and Implications

The court found in favour of the Plaintiff and held that the Defendant was negligent in the performance of the haemorrhoidectomy, causing the Plaintiff’s anal stenosis and rectovaginal fistula.

The direct consequence of this decision is that the Plaintiff is entitled to damages for the physical and psychological injuries suffered, including severe pain, distress, and PTSD. The court awarded general damages totaling €175,000, reflecting the severity and duration of the injuries and their impact on the Plaintiff’s personal, social, and employment life, with special damages agreed subject to proof of liability. No new legal precedent was established beyond the application of established principles of medical negligence and causation.