[2025] EWHC 2025 (KB)

The operation note made by the defendant on 13 June 2019 records his findings as (of relevance):

The defendant’s letter which was dictated after a follow up consultation with the claimant stated (of relevance), “I performed a ligasure haemorrhoidectomy on the 13^th June 2019 for circumferential grade III and IV haemorrhoids. She had large bulky skin tags associated with this.”

The references to a clock face in the operation note are to designate where the haemorrhoids were found. The defendant said these were his clinical findings while the claimant was under anaesthetic. His practice was to reassess the patient’s haemorrhoids using a proctoscope while the patient was under general anaesthetic and before starting surgery. If during this reassessment he had found only Grade 2 haemorrhoids he would not have gone on to perform the surgery and would have performed a banding exercise instead. Surgery was only indicated if the haemorrhoids were Grade 3 or 4. He said that skin tags are generally found in the same place as the haemorrhoids as the skin tag is usually the external skin component of the haemorrhoid.

When he assessed the claimant during the operation he found grade 4 haemorrhoids. He said that it is possible that the claimant had developed grade 4 haemorrhoids between the last time he examined her in March 2019 and the date of the operation, or that he under graded her haemorrhoids previously because when patients are assessed in clinic a grade 4 haemorrhoid is not necessarily noticed because a clinical examination is carried out when the patient is tense and uncomfortable. This changes when the patient is under anaesthetic and completely relaxed with a relaxed anal sphincter, so it is perfectly possible to have different findings at surgery. Grade 4 means that he saw a prolapsing haemorrhoid, tried to push it back in but it wouldn’t stay inside.

Professor Phillips said that it would be impossible to write Grade 3 / 4 haemorrhoids in the operation note and letter without evidence of prolapse because these are defining words. He said that he did not consider it a real possibility that the defendant was mistaken when he wrote this grading. The fact that grade 4 haemorrhoids were found during the operation means that at this time he found that she had prolapsed haemorrhoids which prolapsed again after he digitally pushed them inside.

He said that haemorrhoids do progress over time, so it is possible that the claimant had developed grade 4 haemorrhoids between the previous examination and the date of the operation. However, he considered that a more likely explanation is that when the claimant was under anaesthetic, her legs were in stirrups (in the lithotomy position) which creates quite a high inter abdominal pressure which in turn creates an expulsive pressure in the bottom. This is unlike being examined in clinic when the patient is on their left side and the inter abdominal pressure is not high. Therefore, a grade 3 haemorrhoid which is returnable on examination in clinic, becomes a grade 4 in the operating theatre because the higher expulsive pressure pushes the haemorrhoid out again when it is returned.