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Haemorrhoid grading system
Haemorrhoid grading system
At this point, it is relevant to set out the grading system that both parties agree is used by all colorectal clinicians to grade haemorrhoids:
Grade 1 – haemorrhoids are small swellings on the inside lining of the anus. They cannot be seen or felt from outside the anus. They bleed but do not prolapse (bulge out of the anus).
Grade 2 – larger haemorrhoids which can prolapse out of the anus (for example when defecating) but spontaneously disappear back inside the anus.
Grade 3 – haemorrhoids prolapse from the anus and may be felt as small, soft lumps that hang from the anus. However, these can be pushed back inside the anus using a finger.
Grade 4 – haemorrhoids permanently hang down from within the anus and cannot be pushed back inside. They sometimes become quite large.
The expert witnesses called by the parties agree that if the claimant’s haemorrhoids were in fact grade 1 or 2, then surgery was not indicated and should not have been offered to the claimant nor performed. If however, her haemorrhoids were grade 3 or 4, then surgery (a ligasure haemorrhoidectomy) was indicated as this is the most successful and definitive treatment, but the claimant should still have been advised about the alternatives of non-surgical treatment options. The experts’ opinions accord with the literature with which I was provided (see in particular “Haemorrhoids: an update on management. Brown SR. Therapeutic Advances in Chronic Disease 2017: 8 (10): 141-147” and “Haemorrhoids: modern diagnosis and management. Hollingshead JRF and Phillips RKS. Postgraduate Medical Journal 2016: 92: 4-8”.
- Heading
- Ms Sarah Clarke KC Sitting as a Deputy Judge of the High Court
- Haemorrhoid grading system
- The issues to be decided in this trial
- Causation
- Burden and standard of proof
- Counsel
- The applicable law In Hunter v Hanley [1955] SC 200, at [204] (“ Hunter ”), Lord President Clyde held that: “…[a surgeon] is not negligent merely because his conclusion differs from that of other professional men, nor b
- In Bolam v Friern Hospital Management Committee [1957] 1 WLR 583, at [587] (“ Bolam ”), Mr Justice McNair summarised the test as follows: “…[a surgeon] is not guilty of negligence if he has acted in a
- The House of Lords subsequently qualified the Bolam test in Bolitho v Hackney HA [1998] AC 232 (“ Bolitho ”), at [241H]-[242A] (Lord Browne-Wilkinson) by explaining that, “The use of these adjectives
- Consenting a patient to a procedure In Montgomery v Lanarkshire Health Board [2015] UKSC 11 , at [86] to [87] (“ Montgomery ”) the Supreme Court held in relation to the issue of appropriate consenting of a patient to a procedure
- Where the advice given by the doctor for the purposes of consent is informed by clinical judgment, the approach described in Hunter and Bolam remains applicable to that exercise of clinical judgment (
- Causation In Chester v Afshar [2004] UKHL 41 (“Chester”), the majority of the House of Lords held that causation will be established not only in respect of a patient who would have declined the surgery if prope
- Section 16
- The approach to witness evidence generally
- The witnesses
- The claimant
- The defendant
- Expert evidence
- The claimant’s expert witness – Mr Michael Thompson (“Mr Thompson”)
- The defendant’s expert witness – Professor Robin Phillips (“Professor Phillips”)
- Relevant facts, evidence and findings
- The defendant
- The claimant’s history
- The claimant’s appointment with the Private GP
- The GP’s referral letter
- The first consultation with the defendant
- Flexible sigmoidoscopy procedure
- The second consultation with the defendant
- The process of grading the haemorrhoids
- Advice on treatment options and risks of surgery
- The operation
- The operation note and findings
- Letter of complaint
- Causation
- Submissions
- The defendant
- Discussion
- Issues 2 - If the claimant has not proved on the balance of probabilities that the defendant’s grading of her haemorrhoids as grade 2 / 3 was incorrect, then has the claimant established on the balanc
- Issues 3 - 4 – Causation
- Conclusions