Greenhorn (AP) v South Glasgow University Hospitals NHS Trust [2008] ScotCS CSOH

"The lower limbs are placed in Lloyd-Davies supports, which allows good access to the abdomen and vagina. A Foley catheter is inserted to drain the bladder. It is then attached to 500 ml of normal saline and 100 ml is instilled to define the lower bladder edge."

She confirmed that the pursuer was put in the Lloyd-Davies position and a Foley catheter was inserted to drain her bladder. The reason why the patient was put in the Lloyd-Davies position was so that the surgeon could get access to the vagina and the abdomen simultaneously. The purpose of inserting the Foley catheter was to identify the bladder neck, which helped the surgeon in dissecting and in finding where to put sutures later on. She did not attach 500 ml or instil 100 ml of saline in the pursuer's case: she introduced the catheter into the pursuer's urethra, the catheter then went into her bladder and she inflated the balloon on the end of the catheter with 10 ml of saline or water and gently retracted the catheter so that it obstructed the bladder neck. The 500 ml of saline was inserted through the catheter at the end of the procedure in order to distend the empty bladder and aid suprapubic catheterisation. She was assisted in knowing where the bladder was from the balloon in the catheter.

[10] Section 2 under "Preparation" states:

"A Pfannenstiel incision 2-3 cm above the symphysis pubis provides a good approach to the retropubic space and ileopectineal ligaments."

She explained that that was the incision which she used to open the abdomen to get to the bladder and the cave of Retzius to perform the procedure. The symphysis pubis was the bony part to which ran the ileopectineal ligament to which she would attach the sutures in order to perform a Burch colposuspension. She had been taught that you should have one finger breadth above the symphisis pubis so that you could get as close as possible to the ileopectineal ligament.

[11] Section 3 states:

"A swab on sponge-holding forceps acts as a retractor, and long curved scissors are used to displace fat and divide any scar tissue from previous surgery to define the urethra and lower bladder edge. Blood vessels are diathermied."

That generally explained what she did when dealing with the pursuer. The purpose of the swab on sponge-holding forceps to act as a retractor was to displace the perivesical fat in order to try to get to the anterior vaginal wall to place the sutures - really clearing a path. The long curved scissors helped to reflect the tissues to clear the path towards the anterior vaginal wall, but sometimes they were not needed as the tissues could be gently teased away by just using swab dissection and "peanuts", which were little swabs. She could not remember whether she used scissors on the pursuer when displacing the fat. "Diathermied" meant coagulated with heat: that procedure was carried out to stop the blood vessels bleeding. The retractor was held by the assistant surgeon.

[12] Section 4 states:

"The right-handed surgeon applies a second, left glove and inserts the index and middle fingers into the vagina. A finger locates the paraurethral tissue lateral to the urethra and below the bladder edge at the junction of the middle and distal vaginal thirds. The assistant retracts the bladder upwards."

If she were to go by any of the last procedures she had done then she put her left hand into the vagina, which would be good standard practice. It was an operation which involved feel as well as dissection so that the surgeon knew exactly to which part of the vagina he wished to put his stitches. If the surgeon had two fingers in, that was the sort of breadth and dimension of the vagina that he wanted to clear out to put his stitches in. The paraurethral tissue required to be located so that the surgeon did not damage the bladder. The aim was to put the stitches through the vagina and anchor it to the ileopectineal ligament as the surgeon did not want any sutures going into the bladder he reflected it away from the vagina and the paraurethral tissue. In the pursuer's case she reflected the anterior vaginal wall, put her sutures through it and then anchored them through the ileopectineal ligament. The pursuer's bladder was retracted by the assistant surgeon, Dr Hassan. Retraction meant pushing tissue away and reflection meant physically reflecting it with a swab or scissors or the like.

[13] Section 5 states:

"Three gauge 1 Coated VICRYL (Polyglactin 910) sutures on a 30 mm needle (W9213 or W9335, which is J-shaped) are inserted through the right paraurethral tissue (including the vagina) then into the ileopectineal ligament (Figure 6), starting with the lowest. The third suture on each side must be as near as possible to the bladder neck. On the left side the procedure is repeated, starting with the ileopectineal ligament or the paraurethral tissue."

In the pursuer's case she used only two sutures. She used a J-shaped needle and ethibond non-absorbable sutures. She did not put the sutures through the paraurethral tissue. The first stitch was inserted just slightly lateral to the urethra in order to support the bladder neck and the second stitch had to be as lateral as possible to support the proximal urethra without obstructing it. She explained the procedure she adopted when dealing with the pursuer as follows:

"the first stitch goes through the anterior vaginal wall, then you put a clip in it to keep that needle still there because the needle is needed to anchor it to the ileopectineal ligament. Then you put another stitch laterally, so if I remember rightly, usually I start with the right, then move to my left, so the first stitch goes, once I've reflected the anterior vaginal wall, the first stitch goes through the anterior vaginal wall. A clip is put ... the needle is put aside and a fresh needle in the suture goes through the anterior vaginal wall, this time lateral, more towards the pelvic side wall, and the aim of the second stitch is to really support the proximal urethra. The first stitch .. two stitches, then once that's done, it's clipped again. Then I go on to my left side, do the same thing on the left and, once I'm happy that the sutures are anchored in the right position then really the procedure is more or less complete, and the next step being going back again to the right or, if you're already on your left, then I just take one needle, put it through the first ... into the ileopectineal ligament directly above where the suture is being inserted, both those sutures, and then move back to my right and do the same on my right, and then tie it, not obviously as tight as possible. There's some laxity because you don't want to tie it too tightly because then you obstruct the urethra and the patient can't void."

When asked whether she started on the left or the right she replied:

"I always start on my right, go to my left, then once I've put the four stitches, as I'm already on my left, I start putting the needle through the ileopectineal ligament on the left and then go back to my right."

[14] Section 7 reads:

"The extra glove is removed and the sutures on the left side are tied, starting with the lowest. The paraurethral tissue is elevated only as high as it comfortably goes without tension, so that it lies adjacent to the obturator fascia."

She explained that "once the four stitches have been put, you take your hand out, you change your glove and then you put your sutures through the ileopectineal ligament and tie it as outlined in 7." It was not the paraurethral tissue, it was the vaginal wall, which she elevated. If you examined a patient at the end of the procedure you would see a shelf: the aim of the colposuspension was to create a shelf on which the bladder neck and posterior urethra would lie unobstructed. As was stated below the diagram at the end of section 7:

"Thus the proximal urethra is elevated by about 2 cm and lies close to the symphysis pubis."

That was the purpose behind the operation.

[15] Section 8 reads:

"Once haemostasis has been checked, a suction drain and suprapubic catheter are inserted and the wound is closed."

That was the general procedure. With colposuspension there was always a little venous ooze or bleeding and the purpose of the suction drain was to drain it to avoid a collection of blood in the pelvis. The suprapubic catheter was inserted to drain the bladder. She explained the procedure she used for reflection of the bladder as follows:

"It's finger in the vagina and using what we call a Peanuts, which is really a small artery forceps with a little swab. It's purpose-designed for it, and you gently tease your (sic) bladder away from bladder (sic) and paraurethral tissue away from the vagina."

The operation which she performed was closer to that described in the text of Surgery of Female Incontinence (1986) by Stuart Stanton and Emil Tanagho (6/19 of process) than in the text of 6/11 of process. The difference lay in the use of the vaginal wall rather than the paraurethral tissue as the point of contact. The ileopectineal ligaments, which were just ligaments of the pelvic floor that supported the bony pelvis, were used as anchor points for the sutures because they were recognised to be a vascular, although they had a blood supply. The vaginal wall was vascular and you had to be very careful when you did the dissection, but you identified the vessels and dealt with them.

[16] In the records of the Southern General Hospital for the pursuer (6/7 of process) the pre-operative notes at p 33 detailed the surgeons as "Dr Hassan et al" and at p 35 described the pursuer as "34 year old obese ++". Dr Lingam stated that "obese ++" was the opinion of the person assessing the patient. On p 38 the time of arrival in the anaesthetic room was given as 11.35, the time of arrival in theatre as 12.00, the surgeon as Dr Hassan and the first assistant as Dr Seawald. She could not explain why it had been recorded that Dr Seawald was the first assistant. It was Dr Ramsay's operating list, but as he was on holiday Dr Hassan was in charge of the list. As far as she was aware she was doing the list with Dr Hassan assisting her and the record should have shown her as the surgeon and Dr Hassan as the first assistant. The operation note which she completed in handwriting at the end of the procedure was to be found on pp 45-6. According to that note (p 46) the procedure started at 12.10 and finished at 14.10. The purpose of the operation note was to document clearly what was done. It reads as follows:

"Low transverse incision. Routine entry. Bladder reflected off vagina after cave of Retzius opened. 2 sutures ethibond to (R) and (L) side and anchored to ileopectineal ligament. Suprapubic catheter inserted but at that point bleeding noted from (R) side. Dr Hassan took over and took down sutures on (R) side. (R) ileopectineal vessel bleeding and sutures applied. Haemostasis obtain (sic) but bleeding from deep pelvis and lateral vaginal fornix. Several sutures applied to control bleeding unsuccessfully. Dr Carty, Senior Consultant, called in. At this point blood loss about 2 litres. Dr Carty applied sutures to base of bladder and vagina, initially some control but bleeding welling up in pelvis side wall. CRI obturator vessel ligated but bleeding not controlled. Further sutures to deep pelvis but no effect. Blood loss 5 litres. Decision for pelvic vessel embolization. Abdomen packed with two large pack (sic). Bladder integrity checked with Methlyene blue and confirmed. Suprapubic and urethral catheter left. Drain also left. Embolization radiologist arrived and balloon inserted to control bleeding before transfer to ITU and Radiology. Abdomen closed with vicryl and staples to skin. Bleeding appeared to be settling. EBL - 6-7 litres. Radiologist carried out catheterization."

[17] If she remembered correctly she spotted the bleeding first. She could see active bleeding, which was not normal. Before proceeding with the operation she had satisfied herself that there was no bleeding. The bleeding she noted on the right side would have occurred very shortly, five or ten minutes, after she had completed the tying up of the sutures. Dr Hassan took over when she noted the bleeding because she was not sure where it was coming from. As he had more experience in these procedures he said "I'll have a look at it" and took over. He took down the sutures that she had inserted in the anterior vaginal wall attaching it to the ileopectineal ligament. That meant that he cut the knot which she had tied. That then released the ileopectineal ligament from the vaginal wall to allow a better view. The bleeding was coming from a blood vessel, not from the ligament itself. She could not say how it came to be that blood was coming from a blood vessel. It was coming from an area where she had been working with her needle and it was possible and likely that in the course of working there she had penetrated a blood vessel with the needle. She agreed that the reason why blood was seen coming from that area was because she had penetrated a blood vessel in that area with her needle. When it was suggested to her that that should not have happened, she referred to Negura's paper in the International Journal of Urogynaecology, which stated that there was a 25% chance of going through blood vessels when you run through the ileopectineal ligament because of aberrant blood vessels, and often why you tie off the suture the bleeding stops. She then conceded that that was not what happened in this case as there was active blood loss following upon this part of the operation. When Dr Hassan applied ligatures to the ileopectineal vessels he was doing a sort of repair job to either an artery or a vein. It was likely that the bleeding was arterial, but it was just as likely that it was venous. It was probable that it was an artery that was damaged by her needle. Dr Hassan was able to staunch the flow of blood in that area. She could not remember how many sutures he applied. It took him about five to ten minutes to sort out this particular problem. During that period there was blood coming out from that particular vessel, which would have made visibility in the area he was working in difficult, but suction was used to remove the blood to keep the area as dry as possible. After Dr Hassan staunched the blood bleeding was seen coming from another source in the deep pelvis and lateral vaginal fornix on the right side, by which she meant the general area of the vaginal arteries. This was something quite different from what Dr Hassan had repaired. It was very difficult to say whether that bleeding consisted of arterial or venous blood. When she first looked at it she thought it was venous, but that view changed when the embolisation was done. The estimated blood loss was noted as 6 to 7 litres but when looked at later (when the haemoglobin was done and the before and after blood count checked) it was actually less. Dr Hassan applied several sutures in this area but was not successful and he called for Dr Carty, the consultant on call that day. Dr Carty applied sutures in the same area and ligated the obturator vessel (another branch of the internal iliac artery), but that did not work and he then applied further sutures to the deep pelvis in the same area but that did not work. Dr Carty then decided that he wanted to consider pelvic vessel embolisation because the blood loss was not being controlled. An angiogram could identify the vessel that was bleeding and it could be selectively embolised, which mean that the blood vessel in question is stopped from functioning. It was similar to ligating the blood vessel, but it was done radiologically under x-ray control. The abdomen was packed with two large packs to put pressure into the pelvis to stop the bleeding. She gathered that the radiologist put balloons up the femoral artery and then stopped the vessel bleeding until the pursuer was taken to the x-ray department. The abdomen was closed as a temporary measure. The blood loss was more like three or three and a half litres than the six or seven litres which she had estimated. The haemoglobin levels disclosed what the blood levels were before surgery and after transfusion, and if you subtracted one from the other it enabled you to estimate the blood loss. She alone had made the noted estimate of 6-7 litres blood loss. Whichever was the correct estimate, it was a massive blood loss. She had written below the above operation note that the plan was to remove the pack 48 hours later.

[18] The note made by Dr Urquhart, the interventional radiologist, below the above operation note reads as follows:

"Extravasation noted from branch of rt int iliac which was selectively catheterised and embolisation done using gel foam and metallic coil. Good post-procedure result."

Dr Lingam explained that she followed the pursuer to the x-ray department and she remembered Dr Urquhart injecting dye and showing on the x-ray image intensifier the small branch that was bleeding off the internal iliac artery. He showed the dye extravasating out of the vessel, then he embolised it and repeated the test and there was no leakage, suggesting that the vessel was sealed. The radiology report from Dr Urquhart on pp 79-80 reads as follows:

"Embolisation
In the gynaecology theatre 7F sheaths were placed in both common femoral arteries and 10 mm balloons introduced bilaterally. A portable film was taken to confirm positions of the balloons and the left one advanced so that both common iliac arteries were occluded. Patient was then transferred to angiography where selective right internal iliac injection demonstrated marked spasm in a medial branch of the anterior division. This was then cannulated superselectively and contrast extravasation confirmed. Embolisation was performed initially with gelfoam pledgets followed by a 3 cm by 4 mm MR compatible steel coil and this resulted in satisfactory occlusion of flow. Left common iliac injection showed no abnormality so the catheters and sheaths were withdrawn and both ateriotomies closed with perclose."

[19] Dr Lingam explained that the introduction of the balloons was the first step to stop the upstream movement of blood. Sometimes when there was bleeding in an artery it went into spasm and it just kept opening and closing. She was in the angiography suite when Dr Urquhart showed on the x-ray where the bleeding was coming from. She received photographs of the x-rays and subsequently published an article entitled "Angiographic embolisation in the management of pelvic haemorrhage" (7/9 of process), which dealt with the case of the pursuer. In her article she wrote:

"Selective bilateral internal iliac arteriography showed there was extravasation of dye from the anterior division of the right internal iliac artery."

It would be more precise to say that it was the medial branch as that was what Dr Urquhart said in his report. In figure 1 in her article she showed dye coming from what was more accurately a branch of the internal iliac artery.

[20] When Dr Lingam was asked what caused the damage to the branch of the internal iliac artery she replied that she did not really know. She accepted that it was probable that the most likely cause of the bleeding from this branch of the internal iliac artery was her needle. She accepted that a surgeon should not be working in the area of the internal iliac artery and its branches at all when putting sutures into the vaginal wall. She did not accept that if her needle caused the damage she had moved out of position and was careless in carrying out the procedure because sometimes when the surgeon went laterally there were hidden arteries and "it is very possible and very probable that you do pick up an artery." There was a risk that a patient had an aberrant blood or nerve supply and the surgeon did his best to avoid them, but sometimes he could not see them if they were hidden underneath tissue. If they were hidden underneath a bit of fatty tissue you could easily miss them. When the surgeon was clearing a path and reflecting the fatty tissue that could damage an aberrant vessel. On being pressed about this suggestion on her part she replied that she was "happy to say that probably it's not the blunt dissection". As she had said earlier in her evidence, after she carried out the blunt dissection she checked for blood loss and satisfied herself that there was none before proceeding with the rest of the operation.

[21] The note "obese ++" made by the anaesthetist was his opinion of the pursuer, whose weight was 90 kilograms. She was probably not saying that her view was different from that of the anaesthetist. The fact that the pursuer was classified as obese when considering the colposuspension procedure was relevant, but she might have been overweight and not obese. Obesity was defined as twice your expected body weight to your given height. The term "obese ++" was really not scientific at all unless a proper body mass index was used. The strict definition of obesity was twice body mass index. Obesity was associated with complications. The majority of patients who underwent colposuspension were overweight as they could not exercise due to their incontinence. She had operated on both overweight and obese women since she had started doing colposuspensions. The patient whom she operated on that morning immediately before the pursuer was obese. That was the only occasion that Dr Hassan had to assess her competence in carrying out this procedure. Visibility was more difficult when operating on an obese patient because of the fat. The surgeon had to make greater efforts to clear the routes which he needed to clear in order to see what he was doing. There was no specific mention in the pursuer's operation note of fat being cleared away. It would not have been her practice to have recorded that (or the use of the fingers in the vagina). She accepted that she should have indicated with a little more precision where the sutures were placed. A suture put too far laterally and into the pelvic side wall could possibly pick up any of the branches of the internal iliac artery. She disagreed that she had clearly put her needle into a vessel or damaged a vessel in a way she should not have done if she had been exercising reasonable care.

[22] In cross-examination Dr Lingam explained that there were other surgical procedures for dealing with female urinary incontinence but that the only one she had undertaken before August 1999 was the modified Burch colposuspension. Apart from that she had surgical experience of operating within the pelvis by doing hysterectomies and anything related to the female genital tract. The only time that she went into the cave of Retzius was when she was doing a Burch colposuspension. The variant of doing a colposuspension which she had described had no particular name. She had received her training in incontinence surgery at the Glasgow Royal Infirmary under the tutelage of the urologists who did a modified Burch colposuspension, and the closest to that was the Tanagho modification to the Burch colposuspension. The procedure she was taught was the one she used on the pursuer and the one she still used. She was referred to an American text dealing with the historical evolution of colposuspension surgery, Urogynecologic Surgery (2nd Ed, 2000) by W Glenn Hurt (6/17 of process), which states at p 82:

"Retropubic urethropexy or colposuspension procedures are recommended for the treatment of SUI and are most successful in patients who have SUI with hypermobility of the urethrovesical junction."

SUI stood for stress urinary incontinence, the American term for genuine stress incontinence. At p 82, under the heading "Burch Modification" there was set out some of the history of the modification of the procedure by Mr Burch himself. The variation on the procedure that she undertook was to be found on p 84 under the heading "Tanagho Modification". Tanagho believed that the reason why you needed to put a suture quite laterally was to support the proximal urethra, because initially Burch colposuspension was thought to be too obstructive in that it cured the incontinence but the patient was unable to void, so by moving it laterally you were creating a very gentle shelf on which the urethrovesical angle was maintained so that the patient could void normally but still remain continent. The text states:

"In 1976 Tanagho recommended that the suspending sutures in the anterior wall of the vagina be placed as far lateral from the urethra as possible and that they pass through the full thickness of the vaginal wall, sparing the mucosa."

That was with a view to creating the shelf. In inserting the sutures in the vaginal wall when performing a Tanagho modification the surgeon was trying to go as lateral as he could. "Sparing the mucosa" meant the surgeon went just short of the vagina, not through the full thickness of the vagina. Tanagho also recommended the removal of retropubic fat (the fat around that area as well as in the cave of Retzius), but she did not remove any fat. The text goes on:

"The suspending sutures were attached to Cooper's ligaments, not toward the midline, but straight above their location within the vaginal wall."

[23] Cooper's ligaments were the ileopectineal ligaments and that was the procedure which she had described earlier. Having put the sutures as far lateral as she could into the vaginal wall, she then looked for an anchoring point in the ileopectineal ligament directly above the vaginal sutures. The point of doing that was to create a shelf, a bit like s suspension bridge, to suspend the vagina. When examining the patient after the procedure the surgeon could run his hand in the vagina and feel the shelf that the bladder sits on without obstructing the outlet. Where to place the stitches in the ileopectineal ligament was determined in large part by where the stitches had already been placed in the wall of the vagina with a view to the best functional result for the patient. The positioning of the sutures in the ileopectineal ligament was not just a free choice as one was looking at a fairly determined area of the ligament when deciding where precisely to place the sutures. If one went too laterally on the ileopectineal ligament one could damage one of the blood vessels running down the side of the pelvic wall. That was something which she, as a surgeon performing this procedure, would be aware of. Steps were taken to avoid that by visualisation of the ileopectineal ligament and the pelvic side wall and making sure that there were no vessels in that ligament when putting the needle through it. There was some risk of bleeding when the needle was inserted into the ieopectineal ligaments and it was probable that the risk would normally be associated with a heavy and sustained bleed, such as occurred in the case of the pursuer. Such a bleed would be caused because of the aberrant arteries and veins, including obturator veins and arteries. The risk of aberrant blood vessels was increased by previous surgery or infection and there was the fact that no two people have the same anatomy. The pursuer had had a hysterectomy in 1994, during which the uterine artery, the major blood supply to the uterus and vagina, would have been isolated by ligation to reduce the risk of haemorrhage. It would then have shrivelled up and ceased to exist, resulting in a process called angiogenesis, in which collateral circulation could develop to keep the other organs functioning. If that happened, an aberrant blood supply had developed.

[24] In the course of the pursuer's operation no difficulties were encountered until the end of the procedure , when the bleeding was noticed. There had been no difficulty in obtaining visibility of the structures in order to place the initial sutures in the vaginal wall. There were no surgical adhesions from the previous pelvic surgery that the pursuer had undergone. The procedure had been straightforward until the bleeding occurred. When the bleeding was first noticed it appeared to be coming from the right side of the pelvis. It was not apparent from where within the pelvis it was coming. At that point in the procedure it was still possible to visualise the ileopectineal ligament, but only partially. According to her case notes that was where the blood was seen to be coming from. It was possible that the bleeding from the ileopectineal ligament was apparent only when the sutures were cut. The bleed from the ileopectineal ligament was relatively easily dealt with, but the bleeding continued and it was then obvious that the major source of the bleeding was not from the ileopectineal ligament. She could not see where the bleeding was coming from: it was just welling up, which was what happened with bleeding in the pelvis. It was known from the subsequent investigation that the bleed was from an artery. The blood within the arteries was under pressure, so that if a needle were put into an artery it would result in a pulsatile bleed - you see the blood coming out in spurts. With a vein there was hardly any pressure and the blood came out like an ooze. Quite often the pelvis just filled up and you did not know if the bleed was venous or arterial: it could be quite difficult to distinguish between them. Once a significant amount of arterial blood was lost you got a drop in blood pressure. In any event blood pressure might drop under anaesthesia. If she had damaged an artery with her needle it is possible that bleeding would have been delayed due to the artery going into spasm. When the initial stitches were placed into the vaginal wall there was a white background and there was no evident bleeding until 20 minutes or so after these stitches were placed. As she was placing the stitches Dr Hassan was watching and seeing that she was doing the procedure correctly. At no time did he suggest to her that perhaps she was not putting the stitches in the right place or that she was about to put them in the wrong place. If she had damaged a blood vessel with her needle and it ought to have been apparent to her what she was about to do, then it ought also to have been apparent to Dr Hassan. Dr Seawald was a junior registrar and she was just assisting in the operation. This was a procedure done by doctors who had not yet reached consultant grade. At the time she herself was a specialist registrar in the final year of her training and she became a consultant over a year afterwards. She received her Certificate of Specialist Training in July 2000 and was entered into the Specialist Register (which meant she was declared fit to be appointed a consultant) on 20 December 2000, after she had obtained a consultant in September 2000. She started her consultant post in January 2001.

[25] Going back to the damage to the internal iliac artery or a branch of it, she did not really know what caused it. It was a very straightforward procedure and it was not until the end that the bleeding was noted. She thought that if she had caught a blood vessel with her needle she would have known about it. Similarly, she did not really know what was the cause of the bleed from the ileopectineal ligament. She did not know how the haemorrhage from the blood vessel occurred. Unfortunately colposuspension was one of these procedures which was complicated with haemorrhage. Eventually she conceded, in answer to a question from me, that bleeding from the right internal iliac artery could not have been caused by anything other than a sharp instrument penetrating that artery. In the course of blunt dissection blood vessels could be damaged by being torn. Although something was being bluntly dissected it did not mean that the tissues underneath it were not being damaged. Potentially you could injure an artery or tear a bit of an artery and the artery could go into spasm, and initially there may not be any bleeding but later on, once the artery was no longer in spasm, you could have bleeding. That did not require a sharp instrument coming into contact with the artery itself. If a vessel had a friable wall, just touching it would make it break down. In blunt dissection the tissues were exposed to forces during which they were stretched, and that could cause damage to them. Tissues were also exposed to pressure as they were being pushed during blunt dissection and even indirect pressure could cause damage to a blood vessel. Two things could cause damage to a blood vessel - putting a needle through it or blunt dissection. All that was meant by blunt dissection was that an implement was not being used to dissect the tissue - a swab or a sponge on a stick was being used - but that did not mean it was atraumatic and tissues were not being damaged: as soon as you mobilised tissues you were damaging them. She could not remember where in the pursuer's pelvis the ruptured vessel was located. The internal iliac artery was a fairly large vessel which branched into a large number of branches as it entered the pelvis and it supplied the greater part of the pelvis with blood. A branch of the internal iliac artery could be located virtually anywhere within the pelvis. As far as she could remember there was not, during the attempts to staunch the bleeding, any point at which the actual bleeding point was visually identified. She was unable to assist with where precisely within the pelvis the bleeding was coming from. The fact that the bleeding was welling up at the right side of the pelvis did not narrow down the possible points of bleeding as the bleeding could have come from any number of branches of the internal iliac artery and vein.

[26] In re-examination Dr Lingam accepted that according to the radiology report the second blood loss was coming from a medial branch of the internal iliac artery, but pointed out that when they were looking down the pelvis there was bleeding on the right side and there was no way of telling where it was coming from: if they had known where the bleeding was coming from they would have attempted to secure haemostasis. The use of the word "blunt" in describing dissection gave the impression that the surgeon was being very delicate with any dissection, but blunt dissection was still dissection and could still cause trauma to tissue. She considered either a sharp instrument or blunt dissection to be possible causes of the second or major bleed. She did not know whether, looking to the timescales and the nature of the dissection involved, that a sharp instrument was more likely than blunt dissection to have caused the major bleed. She was not aware that the medical literature helped because a lot of the papers published on haemorrhage did not go on to say what the problem was. At the time she thought she saw blood coming from the ileopectineal ligament on the right side. According to the operation note she saw blood coming from a blood vessel. It was possible that the blunt dissection which had taken place sometime before that might have been the cause of the bleed: she did not know. She would not have seen it if the artery had gone into spasm and was hidden in a bit of fatty tissue: the bleeding would occur only when the artery was no longer in spasm. The notion of collateral blood supply was not pure speculation on her part. Notwithstanding the fact that the vagina had its own blood supply, a collateral blood supply could be set up for the vagina in the event of the uterine artery being ligated.

(ii) Dr Hassan
[27] Dr Hassan stated that he first worked with Dr Lingam when she took up her appointment at the Southern General Hospital. He had previously known her only from Royal College meetings. The following passage of evidence indicates his understanding of her experience in colposuspension:

"Now, what was your understanding as to her experience in the colposuspension procedure when she first came to the Southern General? - Yeah, I thought she was interested in urogynaecology, and she was already working with the urologist who's interested in urogynaecology in the Royal Infirmary, and she did colposuspension operations down there when I asked her.

Where? In the Royal Infirmary? - Yes.

So are you telling the court that at a point in time you asked her about what colposuspension operations she had done? - Asked, yes.

And what did she say to you? - she said she was interested in urogynaecology and she worked in the Urology Department and she did colposuspension operations.

Did she give you any indication as to how many she had done prior to her appointment to the Southern General? - I can't remember, so I don't think so.

Would it be of relevance to know how many? - No.

Why not? - Because once she said she had done and she's competent, I just take her word.

...

The Royal Infirmary, and did you know when that was? - Before coming to us.

Were you given any greater clarification than that? - No.

Would it be relevant to know when Dr Lingam had been attached to the Royal Infirmary to see how recent her experience was? - I think if we have got somebody who's a senior registrar who's interested in urogynaecology and doing a urogynaecology job in a Urology Department, I'd be satisfied with that if she told me that.

Well, did you know when she had been attached? - No. I know she's coming from there, but I don't know how long she worked down there.

Did you know when she was working at the Glasgow Royal Infirmary? - No.

Well, did you form any view when considering her experience as to when it might have been, and, in particular, to see how recent her experience in this procedure might have been? - Yes, I asked her just before coming to us, so she came straight from the Royal to us, so these are recent experience. (sic)

Well, were you proceeding on the basis that she had recent experience? - Absolutely.

And when you talk about recent experience, is there any number that you'd have in mind of colposuspension operations that would justify saying someone had appropriate recent experience of the procedure? - I think if she have got about ten cases before coming to us, I'll be satisfied with that.

In recent times? - Absolutely.

And when you say "absolutely" to that, why is it important to have recent experience? - You know that she's doing them and she's acquainted herself with that area since she had been interested in it, so she'll be more or in a better position being a senior registrar. Her experience surgical-wise is more than a normal registrar who would be attached to us.

If I can perhaps put it in a colloquial way, if you're told someone has had recent experience of the number you've mentioned, then you come to the view that she's up to speed, as it were, and able to do the operation competently? Yes.

And when we're talking about doing the operation, do I understand you to be saying that you mean doing the operation as the lead surgeon? - As a separate person taking care of the patient herself or the lead surgeon."

[28] He accepted that if Dr Lingam had done only one colposuspension as lead surgeon in the previous five or six years it might suggest that she lacked recent experience in that procedure, but added that it didn't mean she wouldn't be able to do it. She could be the lead surgeon but her assistant should be more experienced than herself. He would expect that, being a senior registrar, she would be a skilled surgeon, otherwise she wouldn't be a senior registrar. She need not have done ten recent colposuspensions if there was an experienced person with her as her assistant. He had asked her only if she was experienced or not and she said yes: you only asked a very junior doctor how many operations he had done. Recent experience was obviously important. He was confident that before 26 August 1999 she would have assisted at a colposuspension on a number of occasions.

[29] Over 50% of patients undergoing a colposuspension were regarded as obese. You had to take account of a previous hysterectomy when opening at the beginning of the operation. If the patient were obese and had had a previous hysterectomy it might make the procedure slightly difficult for a doctor in training. On the day of the pursuer's operation he was supervising Dr Lingam. The pursuer was 90 kilograms and therefore borderline obesity: if her body mass index was 34 that classified her as obese. They started on the right side. He put the retractor in and retracted it to expose the area: it then self-retained. It was his job to hold the bladder away from the path of the stitch. There was no concern at all about blood loss at that stage. The sutures had been tied and the suprapubic catheter inserted when he noticed the bleeding "because we always look before we go out in any surgery". He was asked in the following passage of evidence about putting the sutures in the ileopectineal ligament:

"So far as the connection from the vaginal wall to the ileopectineal ligament is concerned, where do you put the sutures in the ileopectineal ligament? - Usually put it most medially to the ileopectineal ligament rather than laterally.

Why do you do that? - the medial part of it.

Why? - It's so easy.

And you're further away from the blood vessels? - There is not much ... the ligament itself has not blood vessels, but if you're looking to put it very lateral you have to lift ... you know, you have to lift the abdominal wall a bit more, and you can do it, but you usually put it more medially than far lateral.

Well, what did Dr Lingam do, so far as the ligament was concerned? - Yes, she use the same way I do it because I exposed the ligament for her, so I know exactly where she's going to put it and I knew where she had put it.

So you're saying she put the sutures into the ligament in a medial .. - Yes.

... position, not a lateral position? - No.

Did this form of colposuspension that was being done by Dr Lingam, does it have a particular name? - It's a Burch colposuspension, yes.

We've heard a reference to a Tanagho type. Does that mean anything to you? - No.

"through the full thickness of the vaginal wall, sparing the mucosa", ... and then if you move to the next paragraph "The suspending sutures were attached to Cooper's ligaments, not toward the midline, but straight above their location within the vaginal wall". Now, do I understand that that's putting them into a lateral position? - Yes.

Are you saying Dr Lingam didn't follow this procedure? - I don't think we did that procedure, no.

Well, I'm just asking you about what Dr Lingam did on the day. You're telling the court that she didn't do this procedure? - Not this procedure you're reading now. What we did, we did a Burch colposuspension and we put two stitches at the bladder neck and we attached these to the ileopectineal ligament, not in the lateral part of it - the medial part of it - so that's a different description.

Well, I'm merely asking you as to what Dr Lingam did, and you're saying she did not follow this general procedure with regard to, in particular, placing sutures in a lateral plane? - Yes."

[30] He confirmed, under reference to the operation note, that the bleeding was spotted after the sutures had been tied and the suprapubic catheter inserted. It was very difficult to give an exact time as to how long had elapsed between the tying of the sutures and his spotting the bleeding, but he thought about five to ten minutes. He took over from Dr Lingam when the bleeding was noticed because the most senior surgeon always took over when a complication occurred. There was quite a lot of blood and that affected visibility. It was very difficult at that time to say whether the blood was arterial or venous. He dealt with the problem by taking down the sutures on the right side and applying a stitch to the bleeding right ileopectineal vessel. They then did suction to see where the bleeding was coming from and it was coming from deep in the pelvis. There was bleeding from two separate sources, the first bleeding from the area of the ileopectineal ligament and the second bleeding from an area deep in the pelvis. He thought that most probably the bleeding from the ileopectineal vessel had been caused by the needle going through the ligament and piercing the vessel. It was not the position that Dr Lingam went too far laterally. He would not criticise her if she went too far laterally. He did not accept that the initial bleeding was caused by the suture having been put in a place where it should not have been put. So far as the second bleeding was concerned, an estimated blood loss of six to seven litres suggested that it was more likely that it was arterial bleeding. The bleeding was coming from an area sort of two or three centimetres laterally from where the stitch was put in the vaginal wall. It was coming from the urethra. He tried unsuccessfully to control the bleeding by applying several sutures. Dr Carty's efforts to control the bleeding by applying sutures to the base of the bladder and the vagina were unsuccessful. He thought it was very difficult for him to say why the second bleed had happened. He accepted that Dr Lingam had put sutures into an area proximate to where the bleeding was coming from. It was very difficult to say the stitch caused the bleeding. The commonest reason for injury to a blood vessel was from separation of the bladder itself, by which he meant the reflection of the bladder at the early part of the procedure. An injured blood vessel could retract by moving from its regular position. He was postulating that a vessel had been damaged when the blunt dissection was carried out and that quite some time later blood appeared. It was very difficult to ascertain whether the cause of the second bleed was "contact of the needle or the separation or the lifting of the vagina after we tied it at the end". In order to control the bleeding they had the choice of opening the pursuer's abdomen and ligating the internal iliac vessel surgically or calling the radiologist to embolise the area: they chose the latter option. He understood from the subsequent radiological work that the bleeding had been coming from a medial branch of the right internal iliac artery. The real answer was that they did not know what caused the bleeding. He thought the earlier bleed from the ileopectineal ligament was coincidental and that there was not a significant amount of bleeding from that area. The significant bleeding that caused the problem was from deep in the pelvis, not from the ileopectineal ligament. The fact that there were two sources of blood loss did not tend to suggest that Dr Lingam was not doing the operation properly because he was there and looked at every stitch before she placed it. He asserted that massive haemorrhaging was a rare but recognised problem. He did not agree that if the damage to the medial branch of the ileopectineal ligament was caused by Dr Lingam's needle that showed that she was not doing the operation properly. Stretching the vessel could open and break it, but the lifting of the vagina was not recognised in the medical literature as a complication of this procedure.

[31] He agreed that if Dr Lingam were to do something which was incorrect he had a duty to stop her, but he did not think she had done anything wrong or carried out the operation in any way different from the way it was done in the unit. He totally disagreed that on two occasions she put stitches in locations where she should not have put them and thus caused the two bleeds.

[32] He had no input into the estimate of six to seven litres blood loss on the operation note: it was not discussed with him. Normally the operation would have lasted a maximum of between 45 minutes and an hour. The following day he, assisted by Dr Seawald, removed the packs from the pursuer. When they were removed there was no active bleeding.

[33] In cross-examination Dr Hassan explained that at the time of the pursuer's operation the unit, headed by Dr Ramsay, was a teaching unit for urogynaecology, which included colposuspension. Since the unit was set up he had been involved in the teaching of junior doctors, including teaching the surgical techniques involved in colposuspension. A specialist registrar had to train for five years before becoming a consultant. In the case of Dr Lingam her speciality was obstetrics and gynaecology. It would be normal for a specialist registrar in urogynaecology to undertake colposuspensions. Dr Lingam left the unit after only two months to move south with her family. By 1999 he was experienced in supervising junior doctors who were carrying out colposuspensions. He had no reservations about Dr Lingam being the lead surgeon for the pursuer's operation. He did not recollect Dr Lingam operating that day as the lead surgeon on the patient before the pursuer, but as the list began at 9 am there must have been at least one other patient before the pursuer. He thought that maybe three quarters of all patients who underwent a colposuspension were overweight. A previous hysterectomy could present a problem of access to the abdomen because of adhesions. It was very unreal to think (as the pursuer pleaded) that before Dr Lingam could properly be allowed to do a colposuspension on an obese patient she would first have to have done at least 30 to 40 colposuspensions on non-obese patients: it was not what happened in life. It would take about two years working full time in the unit to do 40 colposuspensions on non-obese patients. As far as he was aware there was no urogynaecological unit in the country that applied such an approach to the training of registrars. The point of his being there when a junior doctor was operating was so that he could take over in the event of any difficulty or complication occurring.

[34] Dr Hassan was able to recollect the surgery on the pursuer. He had only had one other patient in which there had been such a major blood loss intraoperatively. He saw Dr Lingam insert two sutures in the wall of the pursuer's vagina. At the time he had no concern whatsoever that the placement of these sutures was in any way inappropriate. When she placed those sutures there was no immediate bleeding or any other sign that any damage might have been caused by the sutures. He also saw her insert the sutures in the ileopectineal ligament and had no concern that the placement of those sutures was in any way inappropriate. After those sutures were placed there was no immediate bleeding or sign of any other damage. His own preference was that the sutures be placed in a medial position in the ileopectineal ligament. Some surgeons put in more than two sutures, and the more sutures you put in the more lateral you had to go into the ileopectineal ligament. Once the sutures had gone in both sides of the vagina and both sides of the ileopectineal ligament they had to be tied to bring the neck of the bladder and the vagina upwards so that the vagina ended suspended from the ligament by the sutures. The Foley catheter was then taken out and a special metal catheter put in the bladder until its tip came outside the bladder altogether. That took about 10 to 15 minutes and during that time no bleeding was noted. Once the suprapubic catheter was in, the surgeon had to look around to see that it was safe to close the abdomen. It was at that point that the bleeding was noticed. Before the drain was put in he thought there was "a little" bleeding, more significant than the amount of blood that was normally seen, coming from the right side. There was always a degree of bleeding which could be drained through the suprapubic drain. The bleeding had overflown the pelvis. He then took over the procedure and took down the stitches. After he cut the sutures the blood was still welling up out of the pelvis into the abdominal wound. The blood was sucked out by suction and swabs were used to make the area dry. The only bleeding he saw was a slight stream of blood coming from the ileopectineal ligament and he put a stitch on it and stopped it altogether. The slight stream of blood was not enough to account for the extent of bleeding seen. The point of bleeding was at the medial area of the ileopectineal ligament, in the same sort of area where the sutures had been placed by Dr Lingam. The bleeding was still coming from the pelvis while it was being sucked out. He could not see exactly where it was coming from. His response was to lift the vagina up and place blind stitches in the deep pelvis in the hope that he would catch the bleed. When he saw that that was not going to work he called Dr Carty, the senior consultant on call that day, who came into theatre and unsuccessfully tried to staunch the bleeding by the same method. Dr Urquhart, the interventional radiologist, then became involved, put balloons in to slow the bleeding, removed the pursuer to the angioplasty room, identified the bleeding vessel under x-ray and embolised it. Dr Hassan saw the x-ray view of the bleeding vessel but at that point it was very difficult to tell where the bleeding was coming from relative to the sutures. There was always some degree of bleeding in colposuspension (indeed, in most operations) and that was why a drain was inserted, but the amount of blood loss that was sustained in this case was not normally expected. The amount of blood loss from a damaged vessel was determined by the size of the vessel, whether it was a vein or an artery, the pressure going through the vessel, the proximity of that vessel to the main vessels and the duration of the bleed. The fact that the pursuer was bleeding in an uncontrolled fashion for perhaps about an hour would be a substantial contributory factor to her overall blood loss. If he had been able to identify the source of the bleed, it was likely that he would have been able to stop it with a suture. The principal difficulty was that he could not find the source of the bleed to try to put a stitch in it. Usually in a colposuspension the source of the bleeding was found and the bleeding stopped. There were three possible causes of the damage to the vessel in this case in chronological order: trauma during blunt dissection of the bladder from the vagina, direct damage by a suture needle and trauma to the vessel during elevation of the vagina for the tying of the sutures. Each of these possible causes also required an explanation for the delay in bleeding for a further period of at least 15 minutes. That could be explained by the blood vessel going into spasm. None of these three explanations was more likely than the others. The mere fact that damage was caused by a needle did not in his view mean that the surgeon had not taken enough care: you could always catch a blood vessel with a needle, despite your diligence in avoiding it. It was not always possible to see the blood vessels when you were operating as they might not be seen because they were encased in tissue. In this case he saw and was 100% content with the insertion of each stitch by Dr Lingam. He would not have put the stitches in any different place had he been doing the operation. It was very unlikely that the outcome would have been any different if the surgery had been done by another consultant experienced in this operation.

[35] In re-examination Dr Hassan disputed that it would be highly unlikely that the surgeon would catch a branch of an artery during this particular procedure: as there were three arteries in that area, it was not unlikely to catch one. You did not know where they were. You could see many of the veins because they were bigger than the arteries, but the arteries were sometimes difficult to see. Before you put your needle into the vaginal wall or ileopectineal ligament you would be sure that there were no vessels there by clearing away anything that would cause you concern. Dr Carty was called after there had been a bleed of about a litre, in time say 50 minutes. According to the operation note there had been a blood loss of two litres before he arrived. Any control of the bleeding at that stage was apparent rather than real. He had never, when acting as lead surgeon, had haemorrhaging of this sort: it had always been controllable. It would be fair to describe the initial bleeding as an active blood loss and not realistic to describe it as a minor bleed. He applied only one suture to stop it, contrary to what was noted in the operation note. He had not looked at the operation note shortly after the event. He thought about 10 or 15 minutes had elapsed between the pulling up of the sutures and the appearance of blood. He had witnessed Dr Lingam carrying out a Burch colposuspension.

(iii) Dr Urquhart
[36] Dr Urquhart held the post of Consultant Radiologist at the Southern General Hospital and had a special interest in interventional radiology. He had been a consultant radiologist at Law Hospital from 1990 to 1995, when he moved to the Southern General Hospital.

[37] Dr Urquhart became involved in treating the Pursuer on 26 August 1999 when complications arose in the course of her operation. He was the person referred to in Dr Lingam's note "Embolisation radiologist arrived and balloon inserted to control bleeding". He had been phoned in his department and told there was a problem with some bleeding which was proving difficult to control and asked to attend to help stabilise the patient. When he arrived at the theatre there were packs in place which were controlling the bleeding temporarily and a pack was removed and he was shown that the bleeding was coming from deep in the right side of the pelvis. The packs were replaced to help reduce the blood loss. He had no formal record of when he arrived in theatre, but it was probably about 1.30 pm. He scrubbed up and introduced needles into both common femoral arteries and groins and introduced guide wires into both iliac arteries. He then placed vascular sheaths, through which he put angioplasty balloons, which were inflated by pressure devices to the appropriate pressure. That immediately caused a reduction in blood loss. He then took a portable x-ray, which showed where the balloons were relative to the bony structures and moved one of the balloons, which was a bit lower than the optimal, up a few centimetres. The balloons dramatically reduced the pressure of blood flowing into the pelvis by blocking off the two main arteries. As soon as the balloons were blown up the packs were removed and the pursuer was transferred in an ambulance to the x-ray department to have the definitive procedure carried out. The note on p 46 of the hospital records had been written by his registrar Dr Jay.

[38] Once the pursuer was in the radiology suite he removed the balloon from the left side as he knew the bleeding was coming from the right side. He passed a catheter over the aortic bifurcation from the left iliac artery into the right and did an injection of x-ray contrast, an angiogram of the internal iliac artery to see if he could identify where the bleeding was coming from. The injection did not show any extravasation of contrast but it showed an artery which was in spasm, which is a physiological reaction to bleeding where the artery tries to clamp down and reduce the blood loss. He then used a special guide wire catheter to cannulate that artery directly and took a picture, a further angiographic image, which showed both some spasm in the artery and contrast extravasating from the damaged branch of the internal iliac. The x-ray report at p 79 of the hospital records described the procedure carried out. The embolisation was performed initially with gelfoam pledgets, gelfoam being a sterile gelatine sponge specially designed for that purpose. It was soaked up into small pieces a few millimetres across, soaked in contrast medium which made it soft and injected through the catheter into the affected artery. It was very effective in blocking medium-sized arteries. It was absorbable and would be absorbed after a few days, so because of that, and also because it was a single small branch vessel that was involved, he put in a small metallic coil specially made for the purpose of blocking arteries. Further images were taken which showed that the artery was completely blocked and that there was no contrast extravasating from it. He also took further pictures of the internal iliac artery to check that there were no other branches which appeared to be causing the bleeding and a picture on the left side just to be sure that there were no other arteries involved. He was then sufficiently confident that the bleeding source had been completely dealt with and he removed access to the arteries and closed them. 7/8 of process consisted of subtracted images (that is, minus the bones) which showed the x-ray contrast inside the arteries. He thought it was not really possible to say which anatomically named artery was involved: even if he had had the original x-rays he thought he would have found it difficult to do that. It was a branch of the internal iliac artery which came off medially from about the point where the internal iliac artery divided into its branches. In the image it was coming of a kind of dark spot and heading almost vertically downwards. In Figures 1 and 2 of Dr Lingam's article 7/9 of process showed a dark splodge right in the centre which was the contrast spilling out of the artery into the pelvic cavity: that indicated where the damage, or hole, was in the artery. In his report he stated that the artery involved was a medial branch of the internal iliac artery. The lateral branches could be seen to the left of the image. If there had been no damage to the artery involved you would see it coming further down and, like the other ones, branching into smaller branches to supply organs within the pelvis. A plain x-ray of the abdomen (6/5 of process) taken in the Victoria Infirmary when the pursuer was later admitted there with an infection showed the metallic embolisation coil placed in the damaged artery, about halfway between the midline and the lateral bony wall of the pelvis. The images shown in Dr Lingam's article (about which he did not know until after the event) must have emanated from his department. All the x-rays from his department should have been kept in a film packet, but, as far as he knew, it had never been seen again.

[39] The procedure which he had carried out on the pursuer was not an unusual one: he did selective embolisation of internal iliac artery branches, or of the whole artery on occasions, for a number of different reasons. The commonest one was done electively for treatment of uterine fibroids and it gave him a lot of experience at doing this type of catheterisation. In cases of bleeding he occasionally did it for trauma, particularly pelvic fractures, and for obstetric haemorrhages, particularly postpartum haemorrhages, where patients had uncontrollable bleeding after giving birth. He was relatively inexperienced in the procedure at the time but it went very straightforwardly and he did not find it a particularly difficult procedure to do. The technique of embolisation for treatment of this had first been described in the American Journal of Obstetrics and Gynaecology in 1979. The gynaecologist in this case was sufficiently aware to call upon him to stop the bleeding. By the time he was called upon the pursuer had lost quite a lot of blood. There was no way in which he could be definite about which branch of the internal iliac artery was involved, particularly as the pursuer had had major gynaecological surgery, involving the tying off of arteries supplying organs which had been removed and the opening up of new arteries to supply the tissues within the pelvis. It could be that the branch involved was not even a named branch: it was roughly in the area of the uterine artery and the vaginal arteries in 6/18 of process. It was roughly in the position where you would expect the uterine artery to be, but the pursuer's uterine artery would have been tied off at the time of her hysterectomy.

[40] In cross-examination Dr Urquhart accepted that the pursuer's uterine artery would have been divided when she had her hysterectomy. The remnant would have become permanently blocked and atrophied, but it was likely that other vessels would have opened up to supply the tissues in the area around where surgery had been done. The process of opening up of other arteries was known as collateralisation, and connected to that there was what was sometimes referred to as the collateral blood supply. The bleeding artery might well have been part of a collateral blood supply that developed after the hysterectomy: if it was, while he was not a surgeon, he certainly imagined that the position of the artery would not necessarily have been one that could have been anticipated by a surgeon with a normal knowledge of anatomy. If he had done an angiogram in this type of patient he would not have expected the anatomy of the arteries shown to correspond to any text book picture. On that assumption the pursuer's vessel anatomy might have been unique. If his embolisation service had not been available a vascular surgeon might have been called on to tie off the more major vessels supplying the area: in the case of obstetric haemorrhage that was the traditional way of trying to stem postpartum bleeding before embolisation became better known. It was probably correct that, in the absence of his service, what would have been done would have been that the internal iliac artery itself would have been tied off, but simply tying off one source of blood supply did not necessarily prevent bleeding in a branch vessel. The image from the Victoria Hospital (6/5 of process) was a two-dimensional image of the pursuer lying down. It was not possible to tell from the x-ray image the depth in the pursuer's body at which the metallic coil was appearing, but he knew from the angiographic images and from experience roughly where in the pelvis these vessels were. The x-ray image indicated that the coil was within or at the upper part of the pelvic cavity, and, in terms of being in a medial or lateral branch of the internal iliac arteries, it was clearly in a medial branch because, if it was in a lateral branch, it would be lying much further to the side. There was no anatomical point of reference: it was a relative concept, some of the branches being towards the midline and some towards the lateral aspect. This was a branch of the artery that had branched medially back in towards the pelvic organs. One could not reach any conclusion from the x-ray as to the position of the coil relative to any of the organs within the pelvis. All the x-ray really did was to allow you to orientate the position of the coil, and therefore where the artery was within the bony structures, which were not visible on the angiographic images. It was not close to the lateral bony wall of the pelvis: it was about midway between the pursuer's midline and the lateral bony wall of the pelvis.

[41] Dr Urquhart explained that he had no experience at all in gynaecological surgery and that he was not familiar with the operation of colposuspension. He had never before or since the case of the pursuer been called on to assist surgeons doing a colposuspension. The technical details of the operation were not important to him: all he needed to know was where, in gross terms, the bleeding was thought to be coming from as that shortened quite a lot the procedure of looking for the source of the bleeding. It was not possible, applying his wider experience as a radiologist, to say where the bleed was relative to the ileopectineal ligament as that was not a structure which was imaged in radiology and therefore not one he was really familiar with in radiological terms. His understanding was that the ileopectineal ligament was related to the side wall of the pelvis and the bleed clearly was not close to the side wall of the pelvis. The bleed was about three centimetres medial to the side wall of the pelvis and about four and a half centimetres lateral to the midline.

[42] In re-examination Dr Urqhuart stated that the coil had been placed in an undamaged part of the medial branch, and that the location of the damage was at a point different from the location of the coil, directly inferior to where the coil was placed, as indicated on the angiographic x-rays. In relation to the question of collateral blood supply, the uterine artery provided blood to the uterus and, once the uterus was removed, it would be redundant, but there would be other tissue filling that space and there might be a collateral blood supply developing to the vaginal vault, although the vaginal artery was the primary source. He was not aware that many colposuspensions were carried out on patients who had had hysterectomies and that in these cases no unusual arteries were seen. The x-ray did not tell us anything about whether the medial branch of the pursuer's internal iliac artery had been created as a collateral blood supply.

The evidence of the experts
(i) Dr Alan Brown
[43] Dr Brown held the post of Senior Consultant Obstetrician and Gynaecologist at the Royal Infirmary of Edinburgh, heading a team of about 18 consultants, until his retirement from the National Health Service in May 2004. He had since then carried on private clinical and medico-legal practice. His curriculum vitae is 6/45 of process. He qualified MB, ChB from the University of Edinburgh in 1963, became a member of the Royal College of Obstetricians and Gynaecologists in 1968, became a Fellow of that college in 1981 and a Fellow of the Royal College of Surgeons of Edinburgh, without examination, in 1990. He first became a consultant with an academic appointment at the University Hospital of South Manchester, where he remained for eight years, until he returned to Edinburgh. His major subspecialty interest was urogynaecology. As a senior registrar in Edinburgh between 1970 and 1975 he was seconded with a research fellowship from the Medical Research Council to do urogynaecology training at the Middlesex Hospital in London, where he was trained by Mr Richard Turner Warwick and the radiologist Dr Graham Whiteside. In Manchester he was asked to set up the Urodynamic Unit at the University Hospital of South Manchester. He developed the unit in conjunction with the consultant urologist Robin Barnard and worked with him there for the following eight years. On his return to Edinburgh in 1983 he set up, in conjunction with the urologists, the Urogynaecological Unit at the Western General Hospital. From 1983 his urogynaecological practice had been both in the Western General Hospital, where the diagnostic side of things was done, and the Royal Infirmary, where the surgery was done. Along with another consultant he was responsible for the urogynaecology services and the two of them did virtually all of the urogynaecology for the hospitals' catchment area. Urogynaecology basically encompassed lower urinary tract problems in women. The commonest urinary problem that women had was incontinence, of which there were two types. There was genuine stress incontinence (GSI), which predominantly resulted from childbirth, and overactive bladder (formerly called detrusor instability). Dealing with incontinent patients was the main element of their work. He had first started doing colposuspensions under the guidance of Mr Warwick in London in about 1972. He did colposuspensions, the gold standard procedure, until about 2000 when keyhole surgery and the tension free vaginal tape procedure (a much less traumatic procedure) came in. He had carried out as lead surgeon in the region of 1,000 to 2,000 plus colposuspension operations. He had also had a medico-legal interest since 1979 when he was invited to join the Cases Committee of the Medical Protection Society, one of the three medical defence organisations in the UK. He was on that committee assessing all the obstetrics and gynaecology cases going through over the following 12 to 15 years. When he ceased that he was asked to do medico-legal work. He had produced over 50 publications, including 14 peer-reviewed articles and 18 chapters for text books. He had written predominantly on urogynaecology, sexual dysfunction, medical litigation in obstetrics and gynaecology and some problems of gynaecology in the elderly patient. Both Dr Ramsay and Mr Jarvis were well known to him.

[44] Dr Brown had prepared two reports about this case - the first (6/26 of process) dated 5 September 2001 and the second (6/42 of process) dated 21 June 2005 (which essentially gave an update on the pursuer's condition). When he wrote his first report he was relying on information obtained from the medical records. He had not had statements from Dr Lingam and Dr Hassan but he had listened to their evidence in court. He had written the section of the Digest of Operative Procedures dealing with colposuspension (6/11 of process) in 1992. He explained that colposuspension was a specialist operation as it was done in an area of the abdomen different from the area in which a gynaecologist usually operated. A junior doctor in training would learn to do an abdominal hysterectomy before he would learn to do a colposuspension. In incontinence procedures the surgeon was going into a different area of the pelvis, the retropubic space behind the symphisis pubis. Access to that area was more difficult for the surgeon. The method described by Dr Lingam and Dr Hassan was different from the method he described in the text in that he instilled 100 ml of fluid into the bladder to help define the bladder edge more clearly, whereas they just used the balloon of the Foley catheter to define the bladder neck (the junction of the urethra and bladder edge in the midline), but their method was acceptable. It was important to define the bladder edge so that the surgeon did not damage the bladder and confined the stitches to outwith the urethra and the bladder edge. Fat would then be displaced and any scar tissue from previous surgery divided. That gave access to the area in question. When a vein was cut it was destroyed, but that did not matter. With the Burch procedure the stitches were put just further out from the urethra right up to the level of the ladder neck. To give him a better ability to define the area the surgeon put two fingers into the vagina to elevate it and give him much more control of the situation in the event of troublesome bleeding. What Dr Lingam defined was the Tanagho modification of the Burch procedure, where the stitches are put a little more laterally, so her fingers would therefore be more lateral to where he would put them in the Burch procedure. Having cleared the area of fat and any troublesome blood vessels the surgeon had also to clear the area of the ileopectineal ligament of predominantly fatty tissue. He would then under normal circumstances have about three to three and a half centimetres of ileopectineal ligament there to work with. The surgeon would be standing on the patient's left and working on the right side of the patient's body. He would have two fingers in the vagina with his index finger pressing up on the tissue through the vagina to give him a dome of tissue there and he would take a bite through the whole vagina and go across to the ileopectineal ligament on the same side and put a stitch through that at the nearest good anchoring point. Having done that, he would put a clip on both these sutures and just lay it there. Most surgeons would do two or three stitches. His stitches would be fairly close to the mid-urethra and the second one would be nearer the bladder neck, as shown on Figure 7 in his text. Having done the right side, he would go through the same procedure on the left side and deal with any troublesome bleeding with the diathermy but if it was more problematic he would push his finger up inside the vagina and put a separate stitch on one side and then the other side of the bleeding and then tie it to control the bleeding. Some bleeding was to be expected in the course of this procedure because the area in question was a very vascular area, but it was venous bleeding. It was relatively normal to have some bleeding and that was why a drain was inserted.

[45] So far as the Tanagho modification of the Burch colposuspension was concerned, the problem with colposuspension was that if the surgeon elevated too highly the outlet of the bladder was obstructed and this caused urination difficulties, so Tanagho's idea was to put the stitches more laterally to give a less tight elevation of the bladder neck to make it less likely to cause outlet obstruction. With the Burch procedure the stitches were put through the vaginal wall more towards the midline and pretty close to the urethra, whereas with the Tanagho modification they were put more laterally through the vaginal wall, as shown on p 85 of 6/17 of process. The more lateral the surgeon went in the bladder, the closer he was to the ileopectineal ligament.

[46] The operation note on p 45 of 6/7 of process gave a reasonable amount of information, but he would be expecting a trainee to be giving much more detail in an operation record. He agreed with Dr Lingam that she should have detailed the location of the sutures when she talked about sutures to the right and left side. In any event he had heard the evidence of Dr Lingam and Dr Hassan. Whatever the quantity in terms of litres, the pursuer suffered a massive blood loss during the operation. If the second bleed was caused by Dr Lingam's needle, it was more likely that it was caused when she was working in the paravaginal (and not the ileopectineal) area. The first bleed was in the ileopectineal ligament area. In her evidence Dr Lingam had described the Tanagho modification, whereas in his evidence Dr Hassan had described the Burch colposuspension. These were not the same procedures, and Dr Hassan had not described the same thing as Dr Lingam. When asked for his opinion about why the first episode of bleeding occurred, Dr Brown replied:

"Well, the ileopectineal ligament is an avascular structure. It's a ligament. As in any muscle, there is a tendon at the end of it, and that's what we would call ... It's equivalent to a ligament, and it's a relatively avascular structure, but, of course, you know, it is supplied by blood but at a microvascular level, as it were. The only significant source nearby is lateral to the ileopectineal ligament, and when I'm teaching colpossupension ... when I taught colposuspensions, I made the trainee aware of where that bleeding was so that it could be avoided, and my assumption is that she must have in some way damaged that blood supply."

[47] He had indicated where the blood supply might be in diagram 3.30 of Grant's Anatomy (6/18 of process): he was focusing on the branch from the inferior epigastric artery and vein. It was his understanding that a misplaced stitch caused the first bleed because that was the only significant vascular area near to the ileopectineal ligament. If the surgeon went too far laterally there was a risk that he would hit that area. There was a plexus of veins attached to the artery, and it was the venous area which tended to be more at risk. As bleeding does not occur spontaneously, something must have happened to the blood supply to cause the bleed, and he postulated that it was the needle that caused the bleeding. If the Tanagho modification was being properly carried out that should not happen. Whether it was the Burch method or the Tanagho modification which was being used, there was never a need to go too far laterally on the ileopectineal ligament, because, if you do, you were likely to damage a vessel. Dr Lingam's evidence that she placed one stitch medially and the other as laterally as possible strengthened his feeling that she damaged the right ileopectineal vessel by going too far laterally. With reference to Negura's 1993 article "Haemorrhagic Risks in the Burch Procedure" in the International Urogynaecology Journal (6/46 of process), it had been written, not in one of the first line journals, but in a well-recognised and reputable journal. An aberrant vessel was a vessel which was not normally there. The article stated:

"The retropubic space has a well defined vascular anatomy which must be known to the operating surgeon in order to avoid haemorrhagic complications. Of particular importance are the aberrant obturator vessels, which are always present and are usually hidden in a fat pad at the lateral margin of Cooper's ligament."

He agreed with the first sentence but the second sentence was a contradiction in terms as an aberrant vessel was not there in the majority of cases. At the foot of the page the authors stated:

"The reader must not be confused by the term aberrant, as it is truly a misnomer since the vessels are always present, although usually unseen."

[48] In two other places in the article the authors quoted statements that the aberrant vessel was present in a certain percentage of cases. Under the heading "Initial Entry into the Retropubic Space" the authors stated:

"Approaching the space more medially leads directly to the anterior vesical and retrosymphysial vessels, which may be injured in the process. On the other hand, a more lateral approach may injure the inferior epigastric artery and vein, or the aberrant obturator vessels."

He agreed with the above statement. He also agreed with the statement in the introduction that life-threatening haemorrhage in the Burch procedure was rare. In the pursuer's case the bleed from the ileopectineal ligament was not life-threatening but the second bleed was. The authors of this article appeared to be saying that in 25% of cases there would be damage to the aberrant obturator artery if the surgeon went to the most lateral part of Cooper's ligament. It was certainly not his experience, as Dr Lingam suggested, that there was a 25% chance of causing damage if the surgeon applied sutures to the ligament. It was not an accepted fact that putting stitches into the ileopectineal ligament normally was a problem because colposuspension was the gold standard procedure. In his opinion the article did not give Dr Lingam any justification for asserting that in 25% of cases you will have damage in that area. What the authors were doing in the article was to highlight the aberrant obturator vessel. The reference in the article to vessels being hidden in a fat pad at Cooper's ligament accorded with his own experience. If you wanted to place a suture there you had to clear the fat away so that you could see the vessels. If you put a stitch into a blind area you were likely to do damage, and in this situation you would do damage to one of these vessels.

[49] So far as the second bleed was concerned, it appeared from the evidence of Dr Urquhart that the damage was to a medial branch of the right internal iliac artery (shown in diagram 3.29 of 6/18 of process). If you did damage to an artery it was likely to bleed. If you cut it, it would bleed instantly. Then, because arteries were pulsatile (elastic structures) the bleeding would be spurting, and the bigger the artery the greater the amount of bleeding would be. Then the artery would go into spasm, causing it to contract, but it would still bleed. There was the possibility of the vessel retracting, so that within a minute or two of its having been cut it would have pulled back and become very difficult to see. He was suggesting, on the basis of Dr Urquhart's evidence, that the artery might have pulled back after it bled. It was likely that the artery was the anterior artery branching from the uterine artery close to its origin, not close to the uterus, was the artery that was involved. He was asked if he could postulate how that artery was involved and he replied:

"Well, in colposuspension procedures the constant problem we have are the venous structures because they're easily visible, and we should never see an artery as such. Now, arteries of course are of different sizes, but when they branch and branch, the small ones we of course call arterioles, very small branches, you know, like the branches of a tree, the terminal ones, or the root, and so certainly with a Burch colposuspension I have never been aware of an artery in the area where I put my stitches, and from my discussion with my colleague, because he is more ... he does the Tanagho procedure, he also is not aware of seeing arteries as such, so my assumption is that the second stitch was put lateral to the vaginal area in the region of one of these vessels, these arteries."

[50] Dr Lingam had said that the second stitch was as lateral as possible. He was postulating that the tissue was picked up outwith the vaginal area. He did not believe that would be an aberrant blood vessel to cause the second bleed, as Dr Lingam had suggested. He had certainly had no experience of aberrant vessels when doing a Burch colposuspension, even in patients who had had a hysterectomy, and his colleague had not mentioned any aberrant vessels. If there were a significant aberrant vessel it would be visible. The surgeon should not put the needle into an area if he had not ascertained what vessels might lurk there. Any fat should have been cleared away and there was absolutely no excuse for putting blind sutures in. Fat could be easily displaced and if it were not damage might occur. He did not agree, on the basis of his own experience and his reading of the literature, with averment at p 20E of the Closed Record that major haemorrhage such as that suffered by the pursuer was a recognised complication of colposuspension. The common problem from bleeding with colposuspension was from the veins. In general terms the blood loss from a standard colposuspension, either the Burch or the Tanagho modification, would be less than 500 ml, an amount that could be dealt with without any transfusion.

[51] In "Surgery of Female Incontinence" by Stuart Stanton and Emil Tanagho (6/19 of process) the following was stated at p 100:

"Intraoperative complications include injury to the urethra and bladder, venous haemorrhage from paravesical veins and ureteric ligation. ... Venous haemorrhage is managed by diathermy, over-sewing or the use of Sterispon. Any remaining venous bleeding usually ceases as soon as elevation of the paravaginal fascia has been completed."

Stuart Stanton had been the leading urogynaecologist in this country for 15 or 20 years and this text book was well known. It was relevant that he did not mention arterial bleeding at all, which would be the general experience of surgeons. Dr Brown had found only two articles in the medical literature which mentioned haemorrhaging. One was a Turkish article (6/38 of process) in the Australian and New Zealand Journal of Obstetrics and Gynaecology which he had found on the Internet and which mentioned 10 cases of massive haemorrhage, only 8 of which required blood transfusion, in 360 cases of colposuspension. As their definition of massive haemorrhage was not stated the article had to be discounted. The other article was an American article by Baker and Drutz who stated that blood loss for normal colposuspension ranged from 50 to 1500 ml in their series, but that if the colposuspension was associated with another procedure, such as a hysterectomy, the range was 50 to 5000 ml. He took from that that a colposuspension on its own did not normally give rise to massive haemorrhage. When several procedures were done the blood loss could always be much higher. In his opinion you should not get arterial bleeding at all in the course of a colposuspension. The surgeon should not go into an area where there was a risk of arterial bleeding. In his opinion the second bleed in this case ought not to have occurred. It was his belief that if Dr Hassan had done this operation on his own the second bleed would not have occurred: he would have done it a different way from Dr Lingam, and he had much, much more experience than she had. With the Tanagho approach, although the surgeon went laterally, he did not go outwith the area of the vagina into the area where there were arteries. If that was what Dr Lingam did, that would be a failure on her part. He saw significance in the fact that there were two sources of blood loss in this case. It told him that the procedure was done in an inexpert manner.

[52] On the question of Dr Lingam's experience at the time, he considered her experience in the procedure of colposuspension to have been extremely limited. Considering it had been virtually six years since she had done colposuspensions regularly, her experience was out of date. When dealing with this procedure recent experience was, in his opinion, absolutely crucial. Dr Lingam had done only one colposuspension, possibly two, and observed two in the previous six years. Had she come to his unit he would have had her in theatre doing a hystectomy as she was a fifth year specialist registrar, and he would have seen how she did them and assessed whether she was competent. Then he would have had her assisting him doing colposuspensions. Once she had assisted, re-orientated herself and knew the technique used in his unit and was comfortable with it he would let her do colposuspensions, but not in obese patients. Six years not doing a surgical procedure was a very long time and colposuspension was a specialist procedure in a difficult, inaccessible area of the body: the surgeon therefore had to be re-orientated and comfortable in that area with recent experience. Dr Hassan was not entitled to have accepted Dr Lingam's statement that she was experienced. He did not require to go the length of looking at her curriculum vitae but he should have asked her questions about her colposuspension experience, when it was, how many she had done, where it was, her past and recent experience: you could not take these things for granted. He found it very unsatisfactory that she had been in the unit for a month and not been to theatre to see or assist in a colposupension before she was allowed to do one after a six year gap of doing 16. It was up to the individual surgeon to decide which technique suited him or her, but he would expect anyone who worked with him to do his procedure. He considered it bizarre that Dr Lingam described what she did as the Tanagho procedure and Dr Hassan described it as the Burch procedure. Dr Hassan was not au fait with the Tanagho procedure as such. He had been trianed in and he did the Burch procedure. He had been supervising Dr Lingam doing an operation in a way that he himself would not have done it, although he seemed to think that she was doing a Burch colposuspension. In his view what ought to have happened when Dr Lingam was at the Southern General Hospital, had he been running the unit, was that she would have been in theatre many times assisting him and he would have assisted her, for example, in doing hysterectomies to gauge her general experience, and then he would have expected her to have assisted him on several colposuspensions before allowing her to put some stitches in and then doing the operation under his supervision. When she came to do the procedure he would have expected her to follow the Burch route. If she had been taught the Tanagho approach he would have expected her to learn the Burch procedure in his unit as she would have come to his unit to be trained. She was a year 5 specialist registrar still in training and he would have assessed even the senior specialist registrars who came to him and not have let them operate on their own. On the basis that she was allowed to do one and then another colposuspension on the morning of 26 August 1999 with her training and experience he would fault the supervision she had at the Southern General Hospital. The matter of obesity was of relevance when considering this issue because it was much more straightforward to operate on a thin patient because there was less fat, less blood and the tissues were much closer to you. Obesity added a major extra dimension, particularly in a complicated procedure such as a colposuspension. The fact that she had had a previous hysterectomy would not have had any real relevancy. He would certainly not have allowed Dr Lingam to operate as lead surgeon on the pursuer, whether the pursuer was described as obese or not. He would have allowed her to start on non-obese patients after she had observed him over several cases and he had had the opportunity to assess her surgical skills. He thought she would have had to have done 10 or 15 normal weight patients before he would have allowed her to do the next grade of obesity. He would not allow a junior doctor to do a very obese patient until she had done at least 30 or 40 colposuspensions, and then only under supervision because very obese patients were very, very tricky. The pursuer's BMI was 34 and the BMI of a normal weight patient was 20 to 25. The warning zone, which could be described as overweight, was 25 to 30 and 30 to 40 was described as obese, with 40 to 60 being very obese. 30 to 40 was a significant level of obesity. The anaesthetist considered her to be significantly obese when he noted her as being "obese ++": obesity was a crucial factor in anaesthesia as it made the anaesthetic and endotracheal intubation much more difficult.

[53] On the day of the operation Dr Lingam was being supervised by Dr Hassan. If she was placing sutures out of position he should have noticed that. He should have made clear what had happened and that if it happened again he would take over. His own practice would be to take over if it happened on more than one occasion. If it were the case that sutures were placed out of position for a second time, there was no excuse for Dr Hassan not stopping that. On the first occasion he should have given a warning and told her that she had to do exactly what he said.

[54] Dr Brown was asked for his views on the question of a collateral blood supply. It was averred in the defences at p 17C:

"The pursuer is likely to have developed collateral vaginal blood supply following upon the tying off of the remnant of the pursuer's uterine artery, the pursuer having undergone hysterectomy in 1994."

His observations on that hypothesis were as follows:

"I have done many hundreds of hysterectomies and I have done many hundreds of colposuspensions on patients who have had hysterectomies and I have never seen a collateral blood supply, and I would not expect a collateral blood supply to develop following a hysterectomy because at a hysterectomy the main blood vessel which is tied is the uterine artery, which supplies ... it is the main supply to the body of the uterus and the cervix, which is part of the uterus, and so when the hysterectomy is done, when the uterus is done, when the uterus is removed, there is nothing there so there is no need for a collateral blood supply."

[55] He went on to explain that the uterine artery shrivelled up and became redundant. He had never seen a collateral blood supply. A collateral blood supply became necessary when there was a need to get blood to a particular area of the body. When the uterus was removed the uterine artery shrivelled up and the adjacent structures which might also have been supplied secondarily by the uterine artery now relied on their primary source, the vagina on the vaginal arteries, and the ovary on the ovarian arteries. He had not read or had experience of a collateral blood supply following hysterectomy and he did not believe it existed.

[56] Dr Brown did not accept Dr Hassan's hypothesis that damage to the branch of the internal iliac artery might have been caused by the lifting part of the procedure and that particular vessel being stretched. In every colposuspension, whatever method was used, the tissues were lifted up by a couple of centimetres, and even if an intact vessel were there he would not expect damage to it to occur. If there were any merit in Dr Hassan's hypothesis colposuspension would not have become the gold standard procedure that it was for 30 years: if you were likely on a regular basis to tear arteries when you elevated the tissues the procedure would fall into disrepute. Even if a significant artery were picked up he would find it difficult to believe that it would be damaged to the extent that it would bleed. There was nothing in his experience or in the medical literature to support Dr Hassan's hypothesis on this point.

[57] Later in his evidence Dr Brown pointed out that if you elevate an artery there was the possibility that you could damage it. It was a basic principle of surgical practice that if you were dealing with arteries you should never put them under tension, as that could stretch and damage the artery. Accordingly, if in a colposuspension you did elevate an artery (and he had never seen one and it was his understanding that you did not see one in the Tanagho modification), even an intact one, you could damage it and cause haemorrhage. To have elevated an artery in the course of colposuspension the surgeon would have to have gone well lateral of the vaginal area, right to the side wall of the pelvis. He could put a stitch round it and, if he elevated it, there was the danger that he could traumatise it and cause bleeding, but that should not happen. The medical literature referred to venous haemorrhage and stopping it by elevating the tissue because it was a low pressure system, but there was no mention anywhere of dealing with arteries.

[58] At p 17E of the Closed Record it was averred:

"It is likely that the haemorrhage was caused when Dr Hassan separated or reflected the bladder from the vagina, or when the endopelvic fascia was separated."

In Dr Brown's opinion Dr Hassan did very little separating and reflecting of the bladder, that having been done by Dr Lingam at the start of the procedure, but in any event he thought it highly unlikely that the haemorrhage was caused by separation or reflection of the bladder from the vagina. The tissues were overlain by fat and to clear the area the surgeon had to clear the fat away: by pushing it away he could damage the small vessels, but the resultant bleeding would be instantaneous and dealt with at the time by diathermy or electrocautery. It could not be left because the longer it was left the more bleeding there was and the more difficult it was to see the area. Moreover, such bleeding would always be venous bleeding: he could not conceive of any mechanism whereby the major haemorrhaging in this case could have been caused by that part of the procedure.

[59] Dr Brown had considered the report by Mr Jarvis (7/10 of process) in which the latter stated in para 22:

"The sutures having been placed medially first of all a suitable point is then selected anywhere along the ileopectineal line which does not seem to involve a blood vessel and which can result in satisfactory suspension because it is close enough to the medial suture."

Mr Jarvis appeared to be talking about the ileopectineal ligament and it was difficult to say whether he was talking about the Burch or Tanagho procedure. In the Burch procedure the surgeon sought to place the sutures more medially than laterally and at the nearest point to the placement of the vaginal sutures so that they did not have far to travel. There was no discussion by Mr Jarvis about placing sutures as far laterally as possible. Mr Jarvis was referring exclusively to the ileopectineal ligament and did not mention any deeper bleeding. Dr Brown's view was that the major haemorrhaging was caused at the time when the work was being done to the vaginal wall. Mr Jarvis went on to state:

"It would seem to me that there were two possible causes for the haemorrhage. The first is that during the process of dissection in order to display the ileopectineal line and to dislocate the bladder medially on each side in order to insert sutures bleeding could be caused and this is an inherent risk within the procedure."

The above passage rather suggested he was talking about the Tanagho modification as he was pushing the bladder towards the midline so that he could put the more lateral suture in. The bleeding which Mr Jarvis was talking about was venous bleeding, not torrential bleeding, and it should be easily controlled by diathermy, or, if it were more persistent, by stitch. There was a plexus of veins which could be very thick, very juicy veins and damage to them could cause heavy bleeding, which would be required to be dealt with there and then. Mr Jarvis continued in his report:

"Alternatively, a needle used in placing a suture into the ileopectineal line inadvertently caught a blood vessel in the floor of the operating field, in the underlying muscle, and that bled."

The ileopectineal line was a distinct area which was virtually avascular and there was no muscle in that area. The muscle was much deeper and a stitch being put into the ileopectineal ligament should not be anywhere near a muscle. If the stitch were near a muscle the surgeon was in the wrong place and there was certainly no blood vessel in the floor of the ileopectineal ligament: if he was talking about deeper, then of course there were blood vessels.

[60] At para 25 of his report Mr Jarvis dealt with Dr Lingam's experience as follows:

"Dr Lingam confirms that at the time of the operation she was a final year Trainee Specialist Registrar with a special interest in urogynaecology and had significant previous experience in carrying out colposuspension."

Dr Brown did not agree with that observation. Her experience of colposuspension was as a senior house officer and a senior senior house officer, which were very junior grades, and it was six years before this operation, and then more recently she had done one, at the most two, and observed two, so her experience was very limited and significantly out of date. He was certain that most, if not all, of his urogynaecology specialist colleagues would agree with that. In his opinion there was no room at all for a contrary view to be reasonably held.

[61] In relation to the first bleed Dr Brown had indicated that there was a blood source lateral to the ligament. He concluded that Dr Lingam entered that area because that was the only area where there was a significant blood supply in relation to the ileopectineal ligament, and in her operation note she mentioned the ileopectineal vessel. There were no other vessels in that area capable of providing what she described as an active blood loss. The second bleed was from an arterial source lateral to the vaginal area where Dr Lingam would have been working. His conclusion about how that blood loss occurred was that when she placed her second more lateral suture she either went round an artery or traumatised an artery and the damage occurred in the process of the suture being tied. One would come across a branch of the internal iliac artery well lateral towards the side wall of the pelvis, a distance of the order of two centimetres. He envisaged the major haemorrhaging happening by either the needlepoint being put through the vessel when a suture was being placed, in which case one would expect immediate bleeding, or the wall of the vessel being damaged, in which event it would remain intact for the time being, or the vessel being encircled and damage occurring when the tissue was elevated to suspend it. In relation to the bleed on the ileopectineal ligament side he believed that there had been direct trauma to the vessel or bruising to it. Normally a traumatised vessel bled immediately, but in this case the bleeding came later, which was difficult to understand, unless the vessel wall was traumatised and damage was done in the process of tying. He envisaged trauma from the needle skirting or abrading the vessel wall rather than going through it, which one would expect to cause immediate bleeding. If you traumatised a vessel the first thing you got was bleeding, and the spasm element came in later to contract the vessel and reduce the level of bleeding.

[62] Dr Brown considered the amount of blood loss in the case of the pursuer. The operation note referred to blood loss of five litres and later to an estimated blood loss of about six to seven litres. Those figures represented a massive blood loss, more than one would ever consider possible or acceptable in this sort of operation. The haemoglobin level of 42 grams per litre (p 89 of the records) was a seriously low level of haemoglobin indicating a massive blood loss. The blood pressure recordings after 1pm were of seriously low blood pressure, indicating heavy blood loss. The pursuer was in clinical shock and ephedrine (adrenaline) was administered to raise the blood pressure. The anaesthetist had estimated blood loss at over seven litres, and he would place a great deal of reliance on that. The pursuer's life was in danger. What happened in this case could never be considered a recognised complication of colposuspension, and there was no support in the literature for a contrary view. Nor was there any indication in the medical literature that neurological damage (which the pursuer had suffered) was a recognised consequence of the procedure. It was highly unlikely that you would ever get a blood loss of seven litres from a venous haemorrhage.

[63] Dr Brown explained that, on the basis of his medico-legal work, he was fully aware of the legal test for medical negligence (Hunter v Hanley 1955 SC 200; Bolam v Friern Hospital Management Committee [1957] 1 WLR 582). The following passage then occurred in his evidence:

"But just looking to the first blood loss in the area of the ileopectineal ligament, would causing that with a needle be a failure to exercise the skill and care of an ordinarily competent registrar acting with all reasonable care? - Yes.

And similarly with regard to the second blood loss, would causing that with a needle be a failure to exercise the skill and care of an ordinarily competent registrar acting with ordinary skill? - Yes."

[64] In his report of 5 September 2001 (6/26 of process) he stated in his comments and conclusions at pp 4-6:

"Colposuspension is a very specialised procedure which is performed deep in the pelvis. It is often difficult to do because of such factors as obesity, poor access and increased vascularity. Therefore, it should only be carried out by a gynaecologist experienced in the operation or a senior trainee supervised by an appropriately trained senior colleague."

[65] There were several factors in this case which in my view led to the major problems encountered:

1 Ms Greenhorn was significantly obese
The anaesthetic record states that Ms Greenhorn weighed 90 kg at the time of the operation. Her height is 5' 4", so her Body Mass Index (a calculation of the degree of obesity) was 34, which is almost midway through the 'Obese' category. This colposuspension, therefore, would be technically more difficult and hazardous to perform and it was not a suitable case for a surgeon inexperienced in the procedure.

2 Inappropriate delegation of surgery
It appears that at Ms Greenhorn's colposuspension Dr Lingam was a Senior Registrar and Dr Hassan a Staff Grade doctor. Dr Lingam applied the sutures initially but following the heavy bleeding Dr Hassan took over. The inference from this is that the Senior Registrar was being taught the procedure under the supervision of Dr Hassan. In the context of Ms Greenhorn's degree of obesity this was an inappropriate degree of delegation to Drs Lingam and Hassan. This can lead to an increased risk of complications and this is what happened.

3 Inappropriate placement of sutures
The sutures placed by Dr Lingam damaged the right ileopectineal vessels. This should not have happened as these sutures should have been inserted into the ileopectineal ligament closer to the symphisis pubis, i e well away from the ileopectineal vessels. The supervising surgeon, Dr Hassan, should have ensured that the sutures were appropriately placed, but he did not and this resulted in unnecessary bleeding and replacement of the stitches.

It is also probable that the sutures inserted deep in the right side of the pelvis were inappropriately positioned too laterally, and this resulted in the torrential and uncontrollable haemorrhage which was stopped only after embolisation of a branch of the internal iliac artery.

4 The degree of intraoperative haemorrhage and long-term morbidity experienced by Ms Greenhorn are not recognised sequelae of colposuspension
It is recognised that heavy bleeding may be experienced at colposuspension because of the generous blood supply around the bladder base and urethra. But the excessive haemorrhage which occurred in this case resulted in misplaced sutures disrupting a major blood vessel lying laterally, deep in the pelvis. ...

Thus the degree of morbidity suffered by Ms Greenhorn is a direct result of the surgery and is an unacceptable complication of this colposuspension resulting from substandard and negligent care in my view.

I have been performing colposuspension since 1972 and have never experienced such a massive blood loss at this operation. However, as stated before, it is a specialised procedure which can be very difficult and dangerous when done by inexperienced doctors, and I must conclude that this is likely to have been a major factor in this case.

...

Conclusions
My conclusions are that there has been substandard and negligent care in the management of Ms Greenhorn's colposuspension. This is because:

1 With her level of obesity the colposuspension was not suitable for a trainee surgeon to do.

2 There was inappropriate delegation in this case to Drs Lingam and Hassan, as well as inadequate supervision of Dr Lingam intraoperatively by Dr Hassan.

3 As a result, sutures were misplaced at several stages of the operation which caused torrential and uncontrollable haemorrhage.

4 The degree of intraoperative haemorrhage and the continuing long-term morbidity suffered by Ms Greenhorn are not recognised and acceptable consequences of colposuspension."

[66] He confirmed that these conclusions represented his considered view. So far as conclusion 2 was concerned, he was blaming Dr Hassan for having allowed Dr Lingam to carry out the operation at all as lead surgeon, based on her lack of recent experience. His opinion remained the same after having heard the evidence of Dr Hassan. What he asked her was not sufficient. He should have asked her specifically what her level of experience of colposuspension was and when she had gained that experience. From his evidence it sounded as though he thought that she had come straight from the Royal Infirmary Urology Department, where she had done colposuspensions, to the Southern General Hospital. He seemed to have been labouring under a misapprehension about her experience and he also assumed that because she was a fifth year trainee registrar she had up to date experience. On reconsideration he believed Dr Hassan was an experienced surgeon at colposuspension, so it was reasonable for him to have supervised. He was also blaming Dr Hassan for inadequate supervision of Dr Lingam during the operation, with the result that bleeding occurred in two separate areas. He should have stopped her going to the places where the bleeding was caused.

[67] In cross-examination Dr Brown agreed that a major haemorrhage was simply a haemorrhage in which there had been a large blood loss: it did not have any special or technical meaning beyond indicating a large blood loss, based on the amount and duration of the bleed. The pursuer had bled for about an hour before her bleeding was slowed to a manageable extent. That was a lengthy period over which to bleed. Had Dr Hassan's first stitch to the deep pelvis found the bleeding artery and ligated it that would have stopped the bleeding. This was a major haemorrhage because the vessel continued to bleed for as long as it did. With venous haemorrhage one was always able to find the bleeding and stop it. Here it was an artery that was involved and that was why they were not able to stop the bleeding: you should not be in the position that you cannot find the source of the bleeding because you should never have caused the haemorrhage in the first place. According to the anaesthesia record (6/7 of process, p 35) 14 pints of fluid were administered to return the circulation to its normal situation. The haemoglobin level on 29 August (p 82) showed that over the operation the pursuer had dropped her haemoglobin by 3 grams per litre, so there had been a degree of undertansfusion. He did not accept Mr Jarvis' contention (7/10 of process, para 8) that the level of blood loss was 3.5 litres. Whether it was 3.5 or 7 litres, the pursuer had gone into shock. It was his position that massive haemorrhage was an unknown complication of colposuspension: he had no personal knowledge of it and he had not been able to find any literature concerning it, but not all complications were always written up in the literature, and he accepted it could happen. Even if the bleed from the branch of the interior iliac artery had been only a litre he would still have felt that there had been an inappropriate placement of sutures: it was the source of the haemorrhage that was more relevant than its degree as the surgeon should not be in the area where he could damage an artery. In his experience bleeding in colposuspension was always controllable because of its venous nature. His position was that damage to a branch of the internal iliac artery indicated negligence, whether the blood loss was one litre or seven litres. He was prepared to accept that Dr Hassan and others might well have had experience of a massive haemorrhage in a colposuspension, but it certainly did not feature in the medical literature. Blood loss was always greater when doing concomitant surgery because more than one operation was being done. In this case what was done was a colposuspension without additional surgery. The article by Negura et al in 1993 appeared to be suggesting that in the authors' experience there could be severe bleeding by damage to an artery by a needle in the vaginal area during a colposuspension, but the article was not a major article, it gave their impression based on the Romanian experience and it was not something that he would consider to be a significant addition to the literature of haemorrhage in colposuspension. His reading of the article was that it was referring to arteriolar, not arterial, bleeding.

[68] Dr Brown accepted that there were large and small arteries, just as there were large and small veins. The veins around the bladder edge and the urethra could be quite substantial. In the area in question arteries tended to be smaller than veins and the surgeon did not see them because they were so small and did not impinge on his operative field. At the point of the vaginal artery and the vaginal vein going down through the pelvic area he imagined that the arteries and veins would be of comparative diameter. Arteries carried (red) oxygenated blood from the lungs to the various organs and muscles and veins carried (bluish) deoxygenated blood back to the lungs. Veins tended to be a bit bluish in colour and, arteries, because they were thicker walled, tended to be whiter. A surgeon could tell immediately on looking what was an artery and what was a vein just from his experience and their appearance. Moreover, arteries pulsated, whereas veins did not, so movement as well as colour distinguished. Veins contained valves that helped conduct the blood. Vessels in the pelvis lay on various structures, such as muscle or fat: they did not pass through empty space. Arteries could be entirely encased in muscle. Spasm and retraction were both forms of reaction to damage sustained by the wall of an artery, which contained elastic tissue and a very thin layer of muscle as well. When an artery was cut the first thing it did was bleed and there would be pulsatile spurting of the blood as it came out. It would thereafter at some point go into spasm (meaning the muscular element of it contracted) to try to reduce the blood loss: it in effect narrowed itself and constricted the amount of blood that was able to escape from it. If there were a hole in the artery wall but the artery were not severed all the way through He would still expect to see blood loss. He would imagine that the artery could then still go into spasm, but it was not a phenomenon that a surgeon would necessarily see happening as it was more of a radiological phenomenon, but he would expect bleeding if an artery were damaged but not transected. He would not know if there would be spasm in that non-transected artery, but for retraction to happen the artery would need to be completely severed. If an artery were damaged by a suture or a needle it was not likely that it would be completely severed: the most likely scenario would be the needle going through the middle of the vessel, damaging it and therefore causing bleeding. Depending on the type of needle, there was the possibility that the vessel could be cut. If a J-shaped needle were to come in contact with an artery the most likely damage would be piercing of the vessel and bleeding. He imagined it would be possible to damage the artery without piercing it. If the needle had not penetrated the vessel but had encircled or skirted it the suture could cause damage during the knot tying process and the elevation of the suture. His position was that if the initial damage to the artery wall was caused by a needle or a suture it was unlikely that the artery at that point would become completely severed. It was known from Dr Urquhart's imaging that the artery in this case was completely severed. If tissues containing an artery were stretched and the artery put under strain it could be torn and there was the possibility if it were put under a lot of tension that it could be transected. On his view there ought to have been bleeding whenever the artery wall in this case was penetrated, whether by a point or by separation. He was postulating that in this case the rupture of the artery wall happened at the tie of tying the sutures and elevating the tissue and not at an earlier stage: if there had been direct damage to an artery earlier one would have expected bleeding at that point. He found the explanation suggested by Dr Hassan and Dr Lingam that the artery might have gone into spasm, preventing any bleeding being evident, difficult to believe. The penetration of the artery wall, whether or not it was a complete severing, in his view occurred when these sections were tied.

[69] Dr Brown accepted that his experience was of doing the Burch colposuspension. He would not expect to see any arteries in his operative field when doing a Burch colposuspension. He had no experience of the Tanagho modification, had never done one and had never been present when one was done. He had no idea that the colposuspension in this case was a Tanagho modification until he had heard the evidence as it was not evident from the operation note. He had stopped doing colposuspensions in 2000. Between 1995 and 2000 he did an operating list once a week and sometimes if there were spare lists he would do another operating list, half as lead surgeon and half watching a junior surgeon doing it. When asked whether he considered himself "competent to do a colposuspension tomorrow" he replied that he would, because of his length of experience, although he would prefer to do it on a non-obese patient to get back into it.

[70] He was postulating that Dr Lingam put her second stitch into tissue other than the wall of the vagina, in the region of the lateral vaginal wall. He did not know that it had a specific name, but it was perhaps muscle tissue or tendonous tissue: he had never been down in that area of the anatomy to see what it might be because in a Burch colposuspension he never had to go there. He was proceeding on the basis of his understanding of the anatomy of the pelvis. He had never seen the area. He was speculating that there was something down there for Dr Lingam to have caught with a stitch. He was familiar with the pearly white vaginal wall: if you pushed up tissue from below you were going to put it under a lot of tension and it was likely to be a pale colour because all the vessels had been stretched and pushed out of the way. It should be fairly obvious when inserting a vaginal stitch that you were putting it in the right place. In his explanation it had to be accepted that, in addition to putting a stitch through the pearly white vaginal wall, Dr Lingam caught an artery. Considering Dr Lingam's level of experience, he did not think it would have been obvious to her that she had caught some other material in her suture, but he would have hoped that it would have been obvious to Dr Hassan. The next stitch would be on the ileopectineal ligament directly above and he was postulating that the ligament suture went beyond the ligament. It was possible that she missed the ligament entirely, and that was what he was suggesting. He was talking about her putting a stitch in the pelvic wall lateral to the ligament. If the blood came from the ileopectineal ligament itself, that would be contrary to the explanation he was postulating. It followed that if the bleed came from the ileopectineal ligament Dr Lingam must have put her stitch somewhere in the ligament. For his explanation that she put the stitch in the pelvic wall to be correct Dr Hassan would not have noticed that she had missed the ligament. One would have expected Dr Hassan to have noticed. The ligament was a pearly white structure and the pelvic wall, where the vessels were, was a bluish colour as it was covered by a plexus of veins. When he put a suture into the ileopectineal ligament he did not get bleeding, so from that he inferred that there were not small blood vessels behind it, but as it was a living structure it had a blood supply. He did not have the experience of putting a needle into the ileopectineal ligament and causing bleeding. The stitch had to go through the back of the ligament, the part one could not see during the operation: the stitch was first inserted on the front of the ligament and it then went through the back. His experience when putting the stitch through the back of the ligament taught him that there was not something behind it. If Dr Hassan was correct that one suture applied to the ileopectineal ligament stopped the first bleed, then Dr Brown accepted that he must be wrong about the bleeding coming from a vessel in the pelvic wall, but the operation note said he applied "sutures" (in the plural).

[71] So far as the main bleed from deep in the pelvis was concerned, Dr Brown accepted that three different possible explanations had been put forward by other witnesses - damage caused during blunt dissection, damage caused by the insertion of stitches and damage caused by the tying of stitches. The blunt dissection was not likely to have been the cause of the bleeding because that was the first thing done in the retropubic space and if there was any damage to vessels in that area you would expect immediate bleeding. He accepted that during blunt dissection blood vessels might be stretched to the point where they tore because scissors as well as swabs were often used to displace tissues. If there was a larger vessel in that area and it was torn, you would expect it to bleed. The delay between the blunt dissection and the bleeding becoming apparent was about 15 to 20 minutes. He could not accept that a vessel might go into spasm and not bleed. When the stitches were being tied if a significant artery had had been included in that area of tissue which was to be elevated and tied he could foresee the possibility of it being stretched and torn during that process - really getting caught up in the stitching process. It was presumably the artery being pulled up with the stitch around it that put it under tension: it was not being garrotted, it was being pulled. If it were elevated to an extreme degree he would envisage there would be "cheese wiring", but that was less likely than just being stretched and torn. The artery would start bleeding as soon as it was torn. Putting the suprapubic catheter in would take in the order of five minutes. The surgeons would be concentrating on making an incision in the abdominal wall and connecting up the catheter: they would not be concentrating on the retropubic space and it was a possibility that they would fail to notice blood coming from deep in the pelvis. If the vessel was torn and eventually gave way there might be a significant delay before the bleeding started. The bleeding would not commence until there was a fracture in the artery wall. The bleeding might be quite small when the artery was torn and increase when it was divided.

[72] When Dr Brown prepared his report (6/26 of process) he had the hospital records and information from the Scottish Health Service about the grade of the surgeons involved and on that basis he reached his initial opinion. He had then no information about what specific experience Dr Lingam and Dr Hassan had in the procedure. He was confident that he could express a professional opinion concerning fault on the basis of the information available to him. He now accepted that Dr Hassan would be an appropriately trained senior colleague. He was able on the basis of the hospital records to reach the view that the sutures had been placed inappropriately because from his experience of the operation one would not normally cause bleeding from the ileopectineal ligament requiring several sutures to stop it and sutures should not have been placed in the lateral side wall in the deep pelvis. He assumed that it was a needle or a suture or the process of completing the procedure that caused the bleeding because bleeding did not happen spontaneously. He inferred in his report that Dr Lingam was being taught the procedure by Dr Hassan because that was why she had come to the unit: he knew that the Southern General Unit was the main unit for teaching junior doctors this technique. He did not feel that Dr Hassan should have delegated this operation to Dr Lingam in view of the pursuer's significant obesity. He said in his report that this was an inappropriate degree of delegation to Drs Hassan and Lingam because he did not at the time know the level of experience of Dr Hassan as a Staff Grade doctor: he would not normally have expected a Staff Grade doctor to be teaching a fifth year senior registrar this operation in an obese patient. He found out about Dr Hassan's experience only within two weeks of giving evidence. Dr Hassan had more experience than many consultants who did colposuspensions, but not more than consultants who specialised in urogynaecology. In general terms one would not have suspected a Staff Grade doctor to have had the level of experience in this operation that Dr Hassan had. In writing his report he had made an assumption as to Dr Hassan's experience. He had said in his report that this could lead to an increased risk of complications and that this was what happened because you were more likely to encounter complications, and indeed serious complications, if you had inexperienced doctors doing operations. He had assumed that the experience of both doctors was relatively low. One reason why he reached the view that there had been substandard and negligent care was because there had been inappropriate placement of sutures, and the other reasons were that the patient was obese and there had been inappropriate delegation of surgery. In his report he had said that "as a result sutures were misplaced at several stages of the operation", but he should have said "two stages". He considered that he had sufficient information in the hospital records to enable him to make the assumptions and reach the conclusions which he did. He would have considered it unwise and substandard practice for whoever allowed her to do a colposuspension at the Queen Mother's Hospital in 1998 to have done so. When he wrote his report he had no idea what her experience was in colposuspension. The opinion which he had expressed in court was based on the evidence given in court by Dr Lingam and Dr Hassan. It was fine for a specialist registrar, appropriately supervised, to do the operation.

[73] Dr Brown did not agree with the view of Mr Jarvis that colposupension was not a particularly difficult operation and did not accept his statement that virtually every gynaecologist in the United Kingdom performs or has performed colposuspension during training or independent practice. He strongly disagreed with eh statement by Mr Jarvis that it was not a procedure to be reserved for the urogynaecologist alone: the view nowadays was that only they should do this procedure, but he would guess that there were still general gynaecologists up and down the country who did colposuspensions. In relation to obesity Mr Jarvis stated at p 12 of his report:

"The difficulty with obesity, potentially, is two-fold. Firstly, because the fatty layer is thicker, it is also more vascular, but that increased vascularity applies only to the fatty layer and the fatty layer in this case was not the cause of the excessive haemorrhage. There is no doubt that obese patients are more likely to have a superficial haematoma post-operatively but that was not a problem in this case. The second problem related to obesity is the potential difficulty of access in that the surgeon may be operating deeper into a wound than would be the situation in a thin patient. However, unless the patient is grossly obese, that is not generally a problem."

Dr Brown did not accept the first and last sentences in the above passage: otherwise he agreed with it. The venous supply tended to be more significant in the fat patient, and "grossly obese" referred to the extreme end of obesity: he described a BMI index of 40 to 60 as very obese, and "grossly obese" was not a term that he used or had seen. He assumed that by "grossly obese" Mr Jarvis meant a BMI index of 50 to 60, but access was always more difficult in obese patients, not just the grossly obese. It was a matter of a difference of opinion: in contrast to Mr Jarvis, he perhaps attached more significance to risks arising from obesity, and his impression would be that the majority of urogynaecology specialists would consider obesity, not just gross obesity, would increase significantly the risks of this operation.

[74] At para 21 of his report Mr Jarvis stated:

"It is further suggested that the surgical technique itself was inappropriate in that the sutures placed in the ileo-pectineal line should have been placed closer to the symphysis pubis and that they were therefore placed too laterlally. It is argued that they were placed too close to the internal iliac artery and that the sutures should not have been placed close to the internal iliac artery."

According to Dr Brown in that passage Mr Jarvis was confusing the ileopectineal sutures and the internal iliac artery. Mr Jarvis continued at para 22:

"There are, however, errors with this logic. Firstly, the records do not say exactly where in the ileopectineal ligaments the sutures were placed. Whilst indeed the bleeding when it occurred was controlled ultimately by embolisation via the right iliac artery, it was not the artery itself but a branch of the artery which was the cause of the bleeding. That branch was not named and perhaps it doesn't even have a name. The exact site of the bleeding was not known. Virtually all of the arteries in the female pelvis will arise from, ultimately, the internal iliac artery. It is the main blood vessel supply to the pelvis. Even a blood vessel in the midline will arise from the internal iliac artery. Secondly, it is not usual practice to place the the sutures in the ileopectineal ligament in a very specific place or indeed to avoid a particular place. The placement of sutures is governed not specifically by the anatomy of the ileopectineal line but where the sutures are in terms of supporting the bladder neck and proximal urethra."

Dr Brown agreed with the above passage with the exception of the statement that it was not usual to place the sutures in the ileopectineal ligament in a very specific place or to avoid a particular place: he disagreed because at the lateral end or beyond the end of the ileopectineal ligament there were blood vessels which needed to be avoided. Initially in the Burch procedure there were four stitches at each side, but that had been modified over the years to two or three.

[75] At para 23 of his report Mr Jarvis stated:

"Haemorrhage is unfortunately an inherent risk in any surgical procedure however careful the surgeon is and however clearly the anatomy is known and displayed. Small blood vessels cannot always be visualised and even a small artery can bleed significantly when caught by a needle or damaged during the process of dissection. Reading these records and the papers so far available to me, I cannot state for certain why the haemorrhage occurred or the exact blood vessel which bled. The degree of bleeding is totally out of keeping with a needle being placed through any of the sutures within the ileopectineal line itself. Those blood vessels are much too small. I do not believe that the internal iliac artery was damaged, but rather a branch of the internal iliac artery. It would seem to me that there were two possible causes for the haemorrhage. The first is that during the process of dissection in order to display the ileopectineal line and to dislocate the bladder medially on each side in order to insert sutures bleeding could be caused and this is an inherent risk within the procedure. This bleeding can be difficult to control. Alternatively, a needle used in placing a suture into the ileopectinael line inadvertently caught a blood vessel in the floor of the operating field, in the underlying muscle, and that bled. I have no way of knowing which of these two was the more likely scenario, although the doctors concerned may have additional information upon this point. I consider very strongly that either of these explanations are (sic) inherent risks within the performance of the operation and do not indicate care below the standard to be expected simply because bleeding occurred."

Dr Brown agreed with the above passage except to the following extent. He did not accept that blunt dissection was the first possible cause of major haemorrhage. He did not know what Mr Jarvis meant by "the floor of the operating field" or "the underlying muscle" as these were not anatomical descriptions. There was not a muscle in relation to the ileopectineal ligament. In the course of a colposuspension, if the stitches were being put in the appropriate and recognised places you would not expect this extent of bleeding. Dr Brown was asked the following question and provided the following answer:

"So can I ask you if it is possible to inadvertently catch a blood vessel with a suture needle, why do you exclude that as a possibility in this case? - Well, with colposuspension, whether it be a Burch procedure or a Tanagho modification, .. the bleeding which one would normally deal with and, from my own experience, from my discussions with my colleagues and from My reading of the literature, is venous bleeding, and, therefore, it is certainly possible to put a stitch through a vessel and, indeed, a vein, but to put it through an artery which bleeds to the extent that this has done, I would consider that the needle must have been placed outwith the normal area that we should be putting stitches in."

[76] Dr Brown strongly disagreed that the artery which was damaged might have been an aberrant artery, perhaps from a collateral supply because of the tying of the uterine artery at hysterectomy as he had done many hundreds of colposuspensions on patients who had had hysterectomies and he had never seen an aberrant blood supply. He could not accept the concept of an aberrant artery following a hysterectomy. He supposed it was possible to have an aberrant artery but he had not been aware of any aberrant blood supply in that area in the many colposuspensions he had done over the years.

[77] In re-examination Dr Brown accepted that the bleeding was controlled or reduced by the packs that were used due to the pressure that they exerted in the area, but there would have been a little bit of bleeding at the same time. The balloon used by Dr Urquhart would have been a better way of controlling the bleeding by blocking the two main arteries in the pelvis. The major blood letting was taking place before these two procedures. His reading of the situation was that the bleeding was uncontrollable in spite of the various stitches inserted because there was retraction of the artery, which was a well recognised surgical phenomenon. The bleeding was uncontrollable because they could not find the source of the bleeding. If the bleeding had been in an area where they ought to have been operating there should not have been any real difficulty in controlling the bleeding. There would be no difficulty in finding the source of venous bleeding. In his opinion arterial damage should not happen during the course of a colposuspension. If the haemorrhaging that Dr Hassan had experienced in Ireland in 1985 was caused by arterial bleeding that reflected substandard performance. In his experience life-threatening haemorrhage in the Burch procedure was not, as stated in the Negura article 6/46 of process, rare: it was non-existent. In his opinion life-threatening haemorrhage in the course of that procedure caused by arterial damage would be as a result of substandard care. There was a distinction to be drawn between arteries and arterioles: arterioles were the much smaller blood vessels which permeated all the tissue and were supplied by the main channels, which were the arteries. Arterioles were very much smaller and more widespread than arteries and were not seen because they were so small and integrated within the tissue generally. If an arteriole were damaged the amount of bleeding would be very much less than that from an artery and it would be much easier to control by electrocautery or sutures. He agreed with the following statement in the Negura article:

"Although Tanagho recommends that the anchoring sutures should be introduced through the anterior vaginal wall as far laterally and parallel to the urethra as possible in a figure-of-eight fashion, the lateral vaginal margins, where the important branches of the long vaginal artery are located, should be protected and avoided. However, if significant bleeding occurs at the lateral margin of the vagina after suture placement, this can be controlled by keeping tension on that suture while other suture are being placed."

Negura was there talking about arteriole bleeding. Arterial bleeding could be controlled in the same way.

[78] When one talked about what was a recognised complication of a particular procedure, such as venous haemorrhaging, it was implicit that the complication in question could occur without negligence on the part of the surgeon. Venous bleeding was a recognised complication of colposuspension but it was his understanding that massive haemorrhaging would always involve substandard or negligent surgery. The surgeon doing a Burch colposuspension did not see arteries but would be able to see arteries in other procedures such as abdominal hysterectomy, where the uterine artery was palpated. Generally he did not see any difficulty in being able to visualise arteries if they were in the operating field. It was his understanding that there were not specific designated arteries visible when the Tanagho modification was being done. Arterioles caused arterial bleeding of a much lesser quantity. If a needle were put through an artery so that it was not transected but the lumen of it was damaged the first thing he would expect to happen would be some bleeding. For an artery to retract it would have to have been severed and the pursuer's artery ended up in a severed condition. He envisaged that that happened because either in the process of inserting the second paravaginal suture a major artery was undermined and left intact or the vessel wall could have been traumatised and the bleeding would have occurred only following the tying of the suture (meaning the elevating of that block of tissue), thereby putting the artery under tension, stretching it and severing it. That mechanism was not inconsistent with the use of a J-shaped needle. The use of a J-shaped needle was a little more difficult than the use of an ordinary round-bodied needle: during the process the arc of movement of the surgeon's hand was much wider, and he presumed that there was involvement of the artery at that point. It should have been obvious to Dr Hassan, if he was paying attention, that Dr Lingam was not doing the Burch method. He himself had had no experience of blood loss when putting the sutures into the ileopectineal ligament: if they were put into the body of the ileopectineal ligament there should be no bleeding. To him the concept of being behind the ileopectineal ligament was a difficult one: in relation to the depth and thickness of it he had not recognised a vessel in the years that he had been putting sutures through that ligament. He could not envisage any way in which the surgeon could make contact with a blood vessel when going through the depth or thickness of the ileopectineal ligament. He could not envisage the first bleed, which was described as an active bleed, being from a minor blood vessel. If, as Dr Lingam thought, it was arterial bleeding, he would say it came from the pubic branch of the inferior epigastric artery, which coursed towards the ileopectineal ligament at its lateral end. If the exact spot of the bleeding could be visualised one suture should be able to deal with it, but if it could not you would need more. If one suture did the trick clearly another would not be applied. In his experience of that area there were the artery and a series of veins and it would therefore be difficult, but not impossible, to deal with the bleeding with one suture.

[79] In relation to the question of the expertise of the surgeons, the fact that there were two separate sources of blood loss had an impact on him when considering that. When doing a colposuspension one would not expect bleeding from the ileopectineal ligament on placing sutures there. One could damage a vein when placing the deeper stitches and that could happen in the best of hands because they were all-pervasive, but that could be dealt with. To have two sources of bleeding in a colposuspension suggested that inexpert surgery was being performed. When medical techniques changed even a consultant required to learn the new technique. In relation to the aberrant blood vessel theory, an aberrant vessel normally applied to the usual route of a vessel not being taken and so it was a normal anatomical variation. In relation to the collateral blood supply theory, this was a well recognised concept anatomically and surgically and happened in gynaecological practice in various situations, but he was not aware from his clinical experience, discussions with colleagues over the years or reading the literature of the presence of a collateral blood supply occurring after abdominal hysterectomy. He did not find any support in Mr Jarvis's report for these two notions.

(ii) Mr Jarvis
[80] Mr Jarvis became a consultant obstetrician and gynaecologist in 1981, having had a special interest in urogynaecology since the mid 1970s. His curriculum vitae is 7/11 of process. He holds the qualifications of BA in Physiology (Oxford, 1969), BM, BCh (Oxford, 1971), MA (Oxford, 1971), FRCS Ed (1975), MRCOG (1977) and FRCOG (1989). He held the post of Consultant in Obstetrics and Gynaecology at St James's University Hospital, Leeds, one of the largest teaching hospitals in Western Europe, from 1981 to 2002, when he retired from the National Health Service, and during the same period he was Honorary Senior Clinical Lecturer at the University of Leeds, where he continued to lecture. He was Consultant in Gynaecology in private practice at the BUPA Hospital, Leeds, a post he had held since 1981. Among other things he had contributed chapters to a series of textbooks and published widely in peer-reviewed journals, particularly in relation to urogynaecology. In clinical practice between a third and a half of his time was spent specifically on urogynaecology. He had over the years performed surgery for GSI, including several hundred colposuspensions. It was part of his role as a consultant gynaecologist to train doctors in the performance of surgical incontinence techniques. He was on the Council and one of the committees of the Medical Defence Union and had lectured at various legal meetings. He was involved in medico-legal work for both claimants (62%) and defendants (37%) and also accepted joint instructions (1%).

[81] Mr Jarvis had prepared a report dated 23 February 2005 (7/10 of process) on the pursuer's case. Since writing his report he had seen Dr Brown's report and been provided with information about the factual evidence given by Dr Lingam, Dr Hassan and Dr Urquhart. The information set out in the report about the pursuer's medical history and the operation was taken from the hospital records. On the basis of the haemoglobin levels noted he thought that the blood loss was in the region of 3.5 litres. He thought that an estimate of 7 litres was an over-estimate of blood loss, but whether the blood loss was 3.5 or 4.5 litres it was still a very, very significant blood loss and he was not in any way underestimating it: it was mandatory that it be staunched. If it had not been staunched the pursuer would probably have died.

[82] Mr Jarvis had not previously seen the curriculum vitae of Dr Lingam (7/4 of process), but was shown it when giving evidence. When he wrote his report he was not aware of the particular pattern of her experience. He thought he had previously seen Dr Hassan's curriculum vitae (7/1 of process). From the theatre logs (7/5 of process) he thought there was no doubt about his ability to supervise a training surgeon doing a colposuspension: he appeared to have carried a rather formidable percentage of the hospital's workload for that type of surgery. In giving his opinion at para 13 of his report he stated that there was a significant blood loss as a complication of the procedure and he had no reason to change that view. The blood loss was significantly greater than one would normally encounter at the procedure and the vast majority of patients who underwent colposuspension did not require any transfusion.

[83] Mr Jarvis stated that in his practice he still performed Burch colposuspensions, but fewer than a small number of years ago because of the increasing popularity of the operation known as the TVT (tension free vaginal tape procedure). He did not think that his colposuspension was either a Burch or a Tanagho: he did it with two non-absorbable sutures placed on either side of the proximal urethra and the bladder neck in order to produce a non-compressible platform. He placed one of the two sutures at a level of where the urethra and bladder joined the bladder neck and the second suture slightly further down towards the patient's legs alongside the proximal urethra: in terms of how close the sutures were to the urethra, he placed them at a position where they would not cut through the urethra but would take a satisfactory bite of the vagina in a place where he had already judged that the vagina could be elevated. Judging where the vagina could be elevated was important. Some surgeons put a finger in the vagina to elevate it, but he did not do that: he had an assistant place a tightly wrapped swab on the end of a sterile instrument into the vagina, directed the assistant's hand to make the swab elevate the vagina and then placed his suture into an elevated part of the vagina without suturing the swab into the vagina. It accorded with his understanding of the Tanagho modification that the surgeon would try to put the second vaginal suture as far laterally as possible in the vaginal wall. He personally did not try to place the suture as far laterally as he could: he consciously attempted to place the suture in the vagina in a place which would give him the elevation which he required. He could think of times when the suture was in a fairly lateral position. As long as the suture was placed in the vagina there were no specific risks attached to placing it in that extreme lateral position. He then placed the lateral bite of the suture anywhere along the ileopectineal line that he believed would result in satisfactory elevation, ensuring that he did not catch one of the many tiny blood vessels that were present on the ileopectineal line: he did not have a specific place that he aimed for, and there was no specific place on the ileopectineal ligament that he tried to avoid. As a generalisation ligaments had very little in terms of blood supply and there were frequently tiny (1, 2 or 3 mm) thin walled vessels on the surface of the ileopectineal ligament. Catching them was a nuisance more than a problem because the bleeding was slight and would stop either with time or with pressure or with diathermy or by inserting a figure-of-eight suture around the bleeding point. It was not a problematical bleed and would certainly not be a bleed that would give the sort of problems which the pursuer suffered, by which he meant the very dramatic loss of blood that she had. He himself had experience of inserting a suture in the ileopectineal ligament and producing a bleed, perhaps in 10% of patients, but he did not recall ever having caused a significant bleed at that point of the procedure. He recalled having to put in a figure-of-eight suture to stop the bleeding in certainly no more than half and perhaps less than half of that 10%. It would not be the first manoeuvre that he would perform: he would first of all use pressure and then diathermy.

[84] Considering para 17 of his report dealing with haemorrhage as a complication of colposuspension, he explained that he was talking about haemorrhage from any point in the operation and trying to observe from the literature the different ways that one might be able to quantify haemorrhage. He was able to find from the literature a range of blood loss associated with colposuspension. There was a paucity of scientifically valid studies in the form of prospective controlled studies. At para 17 he stated:

"Haemorrhage sufficient to require blood transfusion occurs in probably less than 5% of women undergoing colposuspension but significant haemorrhage resulting in the need for further surgery is recorded in 6% of patients undergoing this procedure (Stanton and Cardozo, 1979, British Journal of Obstetrics and Gynaecology, 86, 693-7). A further study shows that 1 woman in 45 who underwent a colposuspension had an intra-operative blood loss of greater than 1 litre (Alcalay, 1995, British Journal of Obstetrics and Gynaecology, 102, 740-5)."

It was his position that the literature supported the above figures.

[85] In relation to the pursuer's more serious haemorrhage, the source of that bleed had been identified as a medial branch of the internal iliac artery. He had seen Dr Lingam's paper (7/9 of process) about this haemorrhage. He was not able to identify from Figure 1 in that article where the artery would be when it began to bleed. It was likely that the vessel concerned was not a named vessel and he could only presume where it was. The fact that it was a branch of the internal iliac artery would mean that it was in the pelvis. It was medial to the pelvic side wall, but that did not go far in identifying the exact point of damage. He suspected that it was a blood vessel which was coursing through muscular tissue in the pelvis, either muscle overlying the pelvic side wall or muscle on the floor of the pelvis. The bleeding was not from the ileopectineal vessels. On first reading the papers he had thought that it was probably the obturator artery that was involved, but he had to exclude that as the bleeding continued after the surgeons had secured the obturator artery. He did not believe it could be any remnant of the uterine artery because the pursuer had previously had an abdominal hysterectomy, but it was possible that it was a vessel which happened to be very close to where the uterine artery was. It could have been a new blood vessel as part of the healing process post-hysterectomy, but it was his belief that it was a branch of the internal iliac artery that had always been there and happened to arise from the internal iliac artery at a point close to where the uterine artery used to arise.

[86] At paras 19 and 20 of his report (cited above) he dealt with Dr Lingam's experience. The more senior trainees who used to be with him in Leeds were almost all fifth year trainees, people who were within 12 months of being considered as appropriately trained for consultant practice, and they would perform under supervision a lot of the surgery, including colposuspension, on patients under his care. Senior trainees had to operate in order to obtain the necessary practical skill: there always had to be a first time for any surgeon with any operation. When he wrote his report he did not specifically know if Dr Lingam had ever previously performed a colposuspension as a lead surgeon. He knew that she had a specific interest in urogynaecology and that she was a final year trainee, and since colposuspension was then the commonest procedure performed, he made the assumption that she had performed colposuspensions as lead surgeon. He thought he also had the report of Dr Carty describing her as an experienced gynaecological surgeon. He also made the assumption that she must necessarily have observed colposuspensions. When he said in his report that, as a general principle, Dr Lingam was a wholly appropriate person to perform the operation he meant that a senior registrar with a specific interest in urogynaecology in the last year of training was a totally appropriate person to perform the operation. So far as the operation itself was concerned, colposuspension could be a technically challenging procedure in patients undergoing a repeat colposuspension, and although the pursuer had undergone previous surgery through the abdominal wall and into the pelvis, the operative area of colposuspension, namely, the retropubic space, was not an area in which there had been previous surgery: it was a matter of knowing the anatomy and performing the dissection, and if the surgeon knew the anatomy and performed the dissection along certain principles it was not a particularly difficult procedure to perform. Gynaecologists in training were expected to be able to perform a wide range of surgery and colposuspension, before the mushrooming of TNT, was the commonest procedure performed for GSI.

[87] Having received further information about Dr Lingam's experience in colposuspension since he wrote his report, he wished to add the qualification that he was concerned that, although she had performed a reasonable number of colposuspensions in the past, she had performed only two in the recent past, one of which was on the same morning, and he did not think that performing two colposuspensions over a period of several years meant someone could be described as having a particular interest in urogynaecology. Had he been the more senior surgeon present with her he would not have had her performing all of the procedure: each of them would have performed half of the procedure. He would have performed the procedure on one half of the pelvis and she, under his supervision, would have performed the procedure on the other half of the pelvis. There was nothing unique in the way he practised and he was sure that was how many others would train or refresh surgeons in the procedure of colposuspension. If he had not personally known her experience he would have made enquiries of her before the operation about her experience in colposuspension. When he first met his senior trainees he asked them to bring him up to date on their surgical experience and if there was any particular surgical procedure that they wished to learn while with him, so he thought he would have known Dr Lingam's experience before the operation began. He would not have begun the operation without knowing what her experience in colposuspension was. If he had had no concerns about how she performed in the first colposuspension of the day it was at least possible that he would have let her do the second operation as lead surgeon under his supervision.

[88] So far as obesity was concerned, there was nothing special about colposuspension in contrast to other procedures which involved incising through the abdominal wall. Obesity gave rise to increased risks for the patient in relation to both the anaesthetic and the surgery. The first problem was getting through the initial fatty layer below the abdominal wall because it was particularly vascular. It could be time consuming and a little frustrating trying to ensure that the fatty layer had stopped bleeding before proceeding deeper. The second problem was potential difficulty of access. Sometimes a long instrument had to be used and he felt he was less in control with it than he was with the instrument he normally used. This was not generally a problem unless the patient was grossly obese. The majority of the patients upon whom he performed colposuspensions were overweight and perhaps about 10% were obese. He believed that the pursuer's BMI of 34 made her fall into the obese category. A final year trainee within a year of the potential of being in independent practice should be able to operate upon obese women. Dr Lingam had to get the experience of operating on obese women in different procedures. The pursuer had had three previous operations through either the same or comparable incisions and he did not believe that that would have added to the difficulties of the colposuspension, although it might cause the surgeon to take slightly longer in reaching the operation site.

[89] In para 21 of his report he dealt with the question of the surgical technique. He understood there to have been two separate sources of two distinct bleeds. So far as the suggested cause of the first bleed was concerned (Dr Lingam missing the ileopectineal ligament and putting her suture into a vascular area of the pelvic wall, thereby causing damage to a blood vessel situated there), it made sense as a theoretical possibility but not as a surgical event. The whole principle of the operation was that the lateral ends of the sutures were placed into the ileopectineal line. Accordingly, if Dr Lingam placed these sutures into an area of fatty tissue lateral to the ileopectineal line, she did not understand the principle of colposuspension, as opposed to having the technical ability to perform the procedure, which seemed to him highly improbable in a final year trainee who had performed or observed 30 colposuspensions. Secondly, she was being supervised by a doctor who probably performed more of the surgery for GSI in the hospital than any other doctor, and he would surely have noted, in the course of either the earlier operation or that on the pursuer, that her practice was to use, not the ileopectineal line, but somewhere else. He did not really understand how that could logically be the site where she put the sutures. If she had been trying to put her suture into the ileopectineal line but missed it and put it into the pelvic wall in error there were three points to be made. First, the ileopectineal line was about five centimetres in length and so a pretty big target to miss totally. Secondly, Dr Hassan would surely have noticed that she was trying to suture the wrong tissue. Thirdly, according to the operation note the sutures were tied and a platform of tissue obtained and then the sutures had to be cut in order to try to obtain access to the bleeding point. If the surgeon put one end of the suture through a piece of fat instead of the ligament and then tried to tie and elevate a platform of tissue, the suture would simply cut out of the fat and there would not be a suture there to take down to try to find the bleeding point. The ileopectineal ligament, which was adherent to bone and a very nice piece of tissue, was used because it was a firm anchor for the suture: the fat pad had no tension and would be wholly useless as an anchor: on being tightened the suture would just cut through the fat and there would be no suture to cut later on. The ileopectineal ligament was very distinctive because it was almost white: fat was yellow, muscular tissue was varying shades of red and muscle often had over it a thin layer of fascia which was white and then dulled down the redness of the muscle, but it was still a reddy-brown colour. He had great difficulty in understanding how any surgeon could mistake a piece of fat for the ileopectineal ligament. If the bleed was from a vessel in the fatty pad and the ileopectineal ligament was sutured, then that suturing ought to have no effect whatsoever on staunching the bleeding. In relation to the major bleed, so far as concerned the suggestion that Dr Lingam, in looking to place her second vaginal wall stitch as laterally as she could, might have gathered up in her suture some adjacent tissue containing the vessel that was damaged, that had to be a possibility. There was connective tissue at the lateral end of the vagina through which there must be vessels running. It was possible that the branch of the internal iliac artery that was damaged could have been in that region in that the blood supply to the upper half of the vagina arose at least in part from a branch of what was previously the uterine artery, which traced back to the internal iliac artery, so pre-hysterectomy some of the blood supply would have been through a branch of the internal iliac artery: some of the smaller vessels that remained might be branches of the internal iliac artery or of the pudenda artery.

[90] In order to put a stitch in the vaginal wall blunt dissection had to be carried out to identify the wall and get all the other tissues away from the vagina itself. There were three possible ways of identifying the vaginal wall. The first was that the fibres of the vagina ran very specifically in a longitudinal direction along the long axis of the vagina and it was the only tissue in that area with fibres running in that direction. The second was that it was a lighter colour than the surrounding tissues. He himself would describe it as light pink but was aware that a lot of people described it as pearly white. The third was either an instrument or a finger in the vagina: the surgeon inside the pelvis should be able to feel either the instrument or the finger in the vagina through a relatively thin area of tissue and he would then positively know that that area of tissue was the vagina. If Dr Lingam had her gloved hand inside the vagina and was elevating it she would be feeling her own finger. Any tissues that might snag in with the lateral suture on the vaginal wall were not the same colour as the vagina; they were reddish, reddy-rust, that sort of colour. The surgeon was trying not to catch other tissue but Mr Jarvis thought that if the surgeon did do so he would be aware that that had happened: it would be very difficult for him to fail to notice. If he were supervising a trainee surgeon he would notice if that had happened and if a complication of the size which occurred in the pursuer's case happened he would record that within the operation note. The suture was tied under tension and if a blood vessel had been caught in it then it was likely but not certain that the blood vessel would not bleed because it would be either kinked or occluded, so if that were the site of the blood vessel the bleeding would probably, but not certainly, cease. If the suggestion were that the piece of tissue with the artery was caught in the lateral vaginal suture and damaged when it was tied, he had difficulty visualising that as an explanation for the bleeding. He did not associate stretching a blood vessel with it snapping and then haemorrhaging and had not known of it ever being described. It was likely that what would happen first to an artery that had been transacted was that the wall of the vessel would go into spasm (muscle contracting being the spasm) and there would be relatively little bleeding initially. If the spasm wore off and the vessel had not clotted then there would be bleeding. He thought that the interval between the transaction and the bleeding could be almost any length of time within reason, ranging from a few seconds through to several minutes. If the vessel were a vein the bleeding would be immediate because veins cannot go into spasm.

[91] In dealing with the possible explanations put forward for the two haemorrhages, Mr Jarvis set out his position as follows:

"Well, what's been put to me have been several different hypotheses and explanations. The lateral pelvic wall fat pad explanation I don't see of any relevance to this case because of the incredulity that I have of mistaking fat for the ileopectineal line and nobody noticing. The concept of a blood vessel close to the lateral wall of the vagina being somehow or other elevated and then snapping, transecting itself and bleeding, it seems to me to be something that, if it were possible, ought to happen in various sites in which we operate from time to time, and I am unaware of such an explanation for any bleeding that I've ever known, and the concept that a blood vessel was directly damaged with a needle has to be a theoretical possibility as one of the possible explanations, but I have not seen such a problem that I'm aware of where the vessel just disappears out of sight. My difficulty is that I just don't know exactly how this major haemorrhage occurred. I have difficulty visualising a mechanism which will explain all the facts that we do know about it."

He explained that he did not really visualise the concept of a vessel that could be transacted lying free within the pelvis and then just disappearing freely out of the way. Most arteries could retract, but very little, because they were not running through a free space. There were some arteries which ran almost through their own channels, but a branch of the internal iliac artery would not be such an artery, and he did not see how it could retract more than a matter of millimetres: he had difficulty with the concept of a vessel which was lying free transacted and able to retract out of the way.

[92] The pelvic floor was essentially a funnel-shaped muscle which ran 360 degrees around the pelvis, arising all around the pelvic side wall and front and back of the bone and meeting in the midline. It supported the organs of the abdomen and certain structures pierced through it, predominantly the urethra, the vagina and the bowel. The pelvic floor essentially surrounded the vagina totally, but there was relatively little of it in front of the vagina. The wall of the pelvis was the outermost area to which the pelvic floor was attached and it therefore surrounded the floor of the pelvis. The pelvic floor and the pelvic wall were distinct but contiguous structures. He could visualise Dr Urquhart's description of the bleeding end of the artery being about 3 cm medial to the bony side wall of the pelvis and about 4.5 cm from the midline. Those measurements suggested it was not a vessel on the pelvic side wall itself that was bleeding, a branch of a vessel on the pelvic side wall: it was not the internal iliac artery that was bleeding but a branch of it. He believed that the vessel must have originated on the pelvic side wall but been situated at its point of bleeding on the pelvic floor. He could say that it was not on the pelvic side wall because of Dr Urquhart's figures and on the evidence from the operation note that blood was welling up below the ileopectineal line he presumed that meant the pelvic floor or perhaps a vessel just above the pelvic floor. He believed that there was no connection between the first bleed from the ligament and the second bleed from the artery: the bleed from the ligament was a relatively trivial venous bleed, which was not uncommon on inserting or removing a suture, whereas the bleed from the artery was a major life-threatening haemorrhage. He himself had had experience of removing a suture from the ileopectineal ligament in a minority of cases because he was not happy with its position in terms of elevation and sometimes it bled and sometimes it did not, but any bleed was very trivial and easy to manage. At para 23 of his report he had stated that haemorrhage was unfortunately an inherent risk in any surgical procedure, however careful the surgeon was and however clearly the anatomy was known and displayed. Surgery involved the dissection and cutting of tissues, which had a blood supply, otherwise they would be non-viable, and bleeding of some degree was therefore an inevitability in surgical procedures. The process of dissection involved tissue separation, either by sharp dissection using scissors or a knife, or by blunt dissection using a finger, and during either of these processes blood vessels might be injured if not first visualised and secured. A small vessel might not be visualised if covered by the tissue through which the surgeon was dissecting. In colposuspension the surgeon came across more veins than arteries. The arteries usually ran through or behind structures. The largest arteries, such as the obturator artery or the internal iliac artery on the pelvic side wall, had names, but most of the blood vessels that a surgeon came across were unnamed branches of named blood vessels. There had to be arterial blood supply in an operation field. There was a correlation between the size of an artery and the amount of blood that might be lost from it: survival after bleeding from the aorta, the largest artery in the body, could be counted in seconds. The internal iliac artery was certainly a major vessel and the bleeding vessel in this case was certainly significant.

[93] In his report Mr Jarvis had stated that he could not state for certain why the haemorrhage occurred or which blood vessel bled. Having since been informed of the evidence, he still did not know the exact blood vessel in that he did not associate it with a name: he merely visualised it as being a branch of the internal iliac artery running away from the pelvic side wall towards the midline of the body and relatively deep down in the pelvis. He could only hypothesise, rather than give a definitive reason, for the bleeding having occurred. It seemed to him that there were two facts which had to be explained: the first was that the bleeding occurred relatively late into the operation, and the second was that the bleeding came from a vessel relatively deep within the pelvis. He thought that at some stage during the operation an artery was damaged, that it went into spasm and retracted to some degree and, as time went on, it relaxed and the major bleeding became apparent. He did not think that such a vessel itself would be found on the ileopectineal line. He could only visualise a vessel having been inadvertently caught by a needle during insertion of sutures on the right, or perhaps less likely, during the dissection, and that it was not seen to bleed at the time but commenced bleeding with time as spasm relaxed. The needle catching an artery was a known risk of the procedure as the needle was very sharp and frequently (as in this case) J-shaped. Although the surgeon tried to control exactly where a needle was in the tissues, it was sometimes quite a difficult manipulation and angulation to make the needle go through the ileopectineal line. Hypothetically he could visualise the needle catching underlying muscle which did not require much to bleed at the time, but an artery within that vessel had been damaged and subsequently bled. He believed that could happen despite appropriate care by the surgeon; he believed that such was an inherent risk of manipulating needles of a non-straight shape within the pelvis. He thought that when he wrote his report he had not fully appreciated the timing at which the major bleed became apparent and, had he done so, he would have said that, while both scenarios were possible, the needle scenario was much more likely than the blunt dissection scenario to have caused the major bleed. The damage could have been caused by attempting to place the suture either into the ileopectineal line or into the vagina. There was no way of identifying at what stage in the procedure the damage was caused, save that it was during the suturing portion of the procedure, putting the two sutures on each side, which meant four bites of tissue for four placements of the needle on each side.

[94] In his report, in relation to the two alternatives which he did identify, he said that he considered very strongly that either of these explanations were inherent risks within the performance of the operation and did not indicate care below the standard to be expected simply because such bleeding occurred. That remained his view in the event that the cause of the bleeding was the hypothesis advanced by him. It remained his view, as stated at para 26 of his report, that significant haemorrhage was an uncommon but well recognised complication of colposuspension, whether the haemorrhage was venous or arterial. He believed the literature was clear and to the effect that between 1% and 5% of patients who underwent colposuspension had a transfusion. His own experience suggested that it was in the lower part of that range. He had no figures on the percentage of patients who had a blood transfusion as large as the one the pursuer received, namely, seven units of blood. The fact that the vagina had been elevated and the sutures to the ileopectineal ligament secured tended to suggest that the incorporation of part of the pelvic floor into the vaginal stitch had not taken place.

[95] The cross-examination of Mr Jarvis began with the subject of Dr Lingam's experience of colposuspension. On being advised in full of the details of her experience, he did not agree that it was sadly lacking but readily acknowledged that it was relatively limited and less than he had understood it to have been when he wrote his report. In the five or six years before her appointment to the Southern General Hospital she had had limited experience of and exposure to colposuspension. If he had been her supervisor, in her first colposuspension there she would either have been assisting him in performing all of it or he would have done half and she would have done half, but he would not have given her the whole of the procedure to do. He would not have had her being lead surgeon on the patient before the pursuer. In relation to the information which ought to have been elicited from her about her previous experience with colposuspension, he would have commenced a conversation with a fairly open question asking about her experience of and exposure to colposuspensions: he thought recent experience in any surgeon was always very important because surgeons, like anybody, could become de-skilled. He saw it as being the duty of the supervisor, before giving her a whole procedure to do as lead surgeon, to satisfy himself that she had appropriate recent experience with the procedure. He thought it was the duty of the supervisor to obtain the information from the trainee, not the other way around. Had he known the true position the language which he used in his report on this subject would not have been as strong as it was since he then understood that she had greater experience than she had. When he wrote his report he had a report from Dr Lingam dated 14 October 2002, which was not a production in the case and he guessed that his knowledge of her experience came from that document. Her experience as outlined to him in court was significantly less than he would have expected from the description of her as a final year trainee with a special interest in urogynaecology. In his report he had stated that she was a wholly appropriate surgeon to perform the procedure, but he would not necessarily say that he would not have used language of that kind had he been aware of the true position. If he had been Dr Hassan and had watched her perform the previous colposuspension totally as lead surgeon (whether that was right or wrong) he would then have made a judgment as to whether or not he would be content with her performing the next operation with him as an assistant, and if his conclusion was that she was sufficiently skilled to be doing this under his supervision, then he would have allowed her to do so. Had he himself been the supervisor on that day, he would have done the first operation with Dr Lingam assisting him and they would have operated half each on the pursuer. In his own practice he was very keen to make trainees progress, but he liked them to progress at a steady rate under his supervision with minimal risk to patients (surgery not being free of risk, even when he performed it). In his practice when he was training a doctor to do colposuspensions he would have had that doctor do other, simpler procedures, such as hysterectomy, removal of ovarian cysts and so on, first of all. Trainees tended to move to more specialist units, such as urogynaecology or gynaecological cancer, fairly late on in their five year training programme and they did procedures such as hysterectomies or ovarian cysts when working in more general units in the earlier part of their training. One took into account a series of factors of which obesity, with consequent difficulty of surgical access, was one.

[96] Mr Jarvis was taken through the operation note composed by Dr Lingam. It did not state where on the ileopectineal ligament the sutures were, but he would not normally have stated where they were anchored. He would have stated that the sutures were attached to the perivesical tissues, which meant the vaginal wall. At para 22 of his report he had assumed that Dr Lingam had placed the vaginal sutures through the anterior vaginal wall and out of the lateral vaginal wall. Where he placed the second suture depended upon what elevation looked like after he had approximated his first suture. By "medially" in his report he was referring to the vaginal bite - then the lateral bite, the ileopectineal bite, was selected. He had presumed that Dr Lingam had done something similar to what he would have done as there was nothing in the operation note to make him think that she had not. He found it more logical to judge the second suture, having approximated but not tied the first as he knew then how much or how little he had to achieve with the second suture. He did not have a consistent place for the second suture because where it was placed depended upon the elevation he had obtained with the first, but it would be very close in its position to the first suture. After reading the transcript of Dr Lingam's evidence, he accepted that she first put two sutures into the vaginal wall and then two sutures into the ileopectineal ligament, which was different from the way he did it. When he wrote his report he had assumed that she had done it the same way as he did. The Tanagho modification involved placing the sutures as far laterally as possible in the vaginal wall, with the proviso that the sutures still went through the full thickness of the vaginal wall (6/17 of process, p 84). His sutures would be slightly medial to the sutures drawn in figure 5-4.10 of the production. His first pass of the needle was closer to the urethra than was shown there, but the exit suture was probably in the same place as shown in the diagram. He had presumed that Dr Lingam would have taken a full thickness bite of the vagina; he was not sure he presumed specifically where in the vagina she took the bites, although, had he made a presumption, he would have presumed that it was done in a manner comparable to the way in which he did it, because he thought that was the way in which most surgeons in the UK did it, rather than the way in which Tanagho did it. At the time he wrote his report he had not been told what she had actually done. It did not follow that if the suture was put in the vaginal wall as far laterally as possible that the surgeon also required to go to a lateral position in the ligament when he came to marry up the suture in the ligament, because the position he went to in the ligament would have been determined by two things - (1) where along the length of the vagina the suture was; and (2) what elevation he was trying to achieve. How medial or lateral the suture was in the vagina did not predetermine where it went on the ileopectineal line. He assumed that she was not making for any specific area in the ileopectineal line, save that she was trying to avoid any visible little vessels there and to achieve a satisfactory elevation. He did not think that the description of the Tanagho modification stating that the suspending sutures were attached to Cooper's ligaments, not toward the midline, but straight above their location within the vaginal wall, was suggesting that the surgeon seek to match up the suture in the lateral end of the vaginal wall and the suture in the ligament. He would have taken that description as meaning that wherever in the vaginal wall, along the length of the vagina, the suture was placed, the surgeon moved virtually horizontally across to the ileopectineal line. If it were the position that Dr Lingam sought to place the sutures in the ligament as far laterally as possible, that was something of which he was unaware at the time of writing his report. He was not aware that her position was that she was carrying out the Tanagho modification and placed her sutures in the vaginal wall as far laterally as possible and matched that up by placing her sutures in the ligament as far laterally as possible. When giving evidence earlier he was proceeding on the assumption that she put her vaginal sutures in laterally, but he was unaware that she always had a specific area of the ileopectineal line that she would aim for. He had been unaware that her approach in the vaginal wall had been to place her sutures as far laterally as possible: he had thought that her aim had been to go into the lateral portion of the vaginal wall. The words "as far lateral as possible" brought a risk of going further than the vaginal wall, but she did not seem to have missed the tissue she was aiming at because there was elevation in this case. The ileopectineal ligament was an absolutely obvious structure and he did not see how a surgeon could misjudge it, whereas he acknowledged that the surgeon could misjudge the vagina.

[98] Arterial bleeding had to be part of the overall risk of bleeding in a colposuspension, albeit not as common as venous bleeding. He believed that the literature referred to bleeding without being more specific about whether it was venous or arterial. The reference in Hurt's article (6/17 of process) was to venous bleeding. The textbook "Surgery of Female Incontinence" (2000) by Stanton and Tanagho (6/19 of process) referred to venous bleeding. He could not offhand point to any literature that would support the proposition that arterial bleeding was a recognised complication of colposuspension, but he could not visualise how all haemorrhage could be only venous when all tissue had an arterial supply and venous drainage. Venous bleeding was more of a problem than arterial bleeding in colposuspension because of the plexus around the vagina. At para 17 of his report he referred to the paper by Stanton and Cardozo (6/33 of process) which mentioned as a possible complication venous haemorrhage requiring laparotomy. He could not say whether the paper by Alcalay specified venous or arterial haemorrhage. He himself had published in 1994 in the British Journal of Obstetrics a survey of the literature but did not believe that he had distinguished between venous and arterial haemorrhage. Arterial haemorrhage was a significant matter in any operation. He accepted that between the mid 1970s and shortly after 2000 colposuspension was the commonest procedure performed in the UK for GSI, but he would not have expected that in the literature there would necessarily have been a major distinction made between arterial and venous haemorrhage. He acknowledged that in this case the pursuer's life was in danger because of the haemorrhaging and he was in absolutely no doubt that the interventional radiologist saved her life. He had had two patients who had had major haemorrhage after colposuspension: one case was venous, and in the other case it was the view of the vascular surgeon that it was the obturator artery that was involved, but the patient did not lose as much blood as the pursuer. He thought he had performed at least 500 colposuspensions over the years.

[99] Mr Jarvis stated that there was no increased risk if the surgeon, in going laterally, nevertheless stayed with the vagina and ileopectineal ligament, but if he went too far laterally and missed the vagina or ileopectineal ligament, then there was an increased chance of hitting the blood vessel. As he had said earlier, the ligament was so visible that he had difficulty in seeing how the reasonably competent surgeon could miss it. If the surgeon went through the ileopectineal ligament, then that was not substandard care: if she missed it, then that was substandard care. If it was an arterial bleed at the area of the ileopectineal ligament then he believed it was from either muscle which lay deep to the pelvic floor or the soft tissue lateral to the ligament. In order to make contact with the muscle the point of the needle would have to penetrate downwards into the muscle during either the process of inserting the needle through the ileopectineal ligament or picking it up and out of the ileopectineal ligament. The muscle would be closer to the ligament towards the front of the pelvis and further away towards the back of the pelvis, about 3 or 4 mm from the ligament at its closest. He was postulating that a surgeon exercising ordinary care and skill in putting a suture through the ligament could nevertheless travel that distance with a J-shaped needle and involve an artery and a muscle with the suture. The soft tissue area lateral to the ileopectineal ligament contained veins and arteries. Almost every vessel within the pelvis could have its origin traced back to the internal iliac artery as that was the main artery to supply the pelvis. He believed that the epigastric artery supplied more superficial tissues, such as the lower abdominal wall itself, rather than the structures deep within the pelvis. If a surgeon totally missed the ileopectineal ligament and inserted a needle lateral to the lateral end of it, then he could pick up an artery or vein in the area of soft tissue being described. He was not able to visualise how the surgeon could take a bite out of the ligament and also make contact with the arterial supply: the J-shaped needle was being manipulated in a vertical plane, and that event would require it to be used in an oblique or horizontal plane.

[100] Mr Jarvis could not visualise how, in putting a suture into the lateral end of the vaginal wall, Dr Lingam could have made contact with a medial branch of the internal iliac artery. His understanding was that after hysterectomy the blood supply to the vagina came exclusively upwards from the vessels below. Diagram 3.29 on p 200 of Grant's Anatomy (6/18 of process) showed the vaginal arteries arising, not from the uterine artery, but from the internal iliac artery itself, and so his objection based on a blood supply only from below would not be valid. Although it was generally stated that the vaginal arteries branched from the uterine artery, Grant was an anatomical expert and his diagram showed vaginal arteries arising as medial branches of the internal iliac artery, totally missing out the uterine artery, and he was prepared to proceed on the basis that Grant's anatomy showed the correct depiction of these vessels. Based on that anatomical layout, a suture which came out of the lateral vaginal wall could make contact with a branch of the vaginal artery. He was not sure that he would expect a surgeon at colposuspension to visualise the vaginal artery or that he had ever done so. Every exit suture that he put in the vagina was as lateral as lateral could be within the vagina because it was coming out of the vagina on the lateral wall: if he placed that suture just a little bit more lateral he would be out of the vaginal wall. When the exit suture came out of the lateral wall of the vagina he picked it up with an instrument. If he continued taking the suture without picking it up and back into his clamp, if he just kept making it move laterally and went too far, that would be substandard because that was not what the operation was designed to do: the operation was designed to pick up the full thickness of the vaginal wall and pick up the needle once it had pierced out of the vagina. He did not accept that it was a more likely explanation that Dr Lingam, in inserting that suture, went too far laterally and made contact with the medial branch of the internal iliac artery than the pelvic floor explanation which he had suggested. A damaged artery had less strength than an undamaged one, so Dr Brown's basic hypothesis about what happened was possible, but he did not see why it should be favoured over his pelvic floor explanation. He accepted that if Dr Brown's hypothesis was the correct one there was substandard care at that part of the operation. If there were two sources of arterial bleeding, although he could not anatomically explain the connection, he would be much less comfortable calling it coincidence. When he accounted for the delay in the massive haemorrhaging by spasm he was thinking of a gap of ten or fifteen minutes. When the damage was caused some blood came out, and how much was a matter of degree depending on the size of the hole made with the needle and the rapidity with which spasm occurred. If (as in this case) the vessel was severed he would expect some blood loss at the time of that occurrence, but how much blood loss there would be would depend upon how quickly (sic) the vessel went into spasm. He believed that the spasm was a very rapid physiological response and from his practical experience it happened almost instantaneously. He was saying that there would be some blood letting, which would stop very quickly (sic).

[102] The first explanation when he wrote his report related to the process of dissection and he said he could not choose between the two possible explanations he was putting forward. He now chose between them. As the suturing was closer in time than the dissection it seemed more logical to look at the suturing than the dissection, which he thought could be discounted. In his report he used the word "inadvertently" as synonymous with "accidentally", meaning the event was not the intention of the surgeon. He was also saying that it was consistent with reasonable care for that to have occurred. He did not know which side Dr Lingam would do first in the operation. It was his practice to do the right side first. He stood on the patient's left to operate on her right side and completely tied up the right side before changing round. He did not make an assumption as to how Dr Lingam did it and he was not sure that the tying was of relevance in his thinking as the injury occurred during the suturing side of things. Whether the haemorrhage was four or six litres did not specifically matter: it was a big haemorrhage.

[103] If Dr Lingam said that she placed her sutures as far laterally as possible and Dr Hassan thought they were placed in a medial position, they both could not be correct. He would have expected Dr Hassan to have been aware where his trainee was placing her sutures, then his level of supervision fell below the standard to be expected. He agreed that suffered a life-threatening major haemorrhage due to damage to a medial branch of the internal iliac artery caused by the operating surgeon and by a suture, or, more precisely, a needle. The damage could not have occurred within the normal operating field, but being out of the normal operating field may be an inherent part of surgery. If the surgeon put the needle through the ileopectineal ligament and out through the vagina major blood vessels were not, as a rule, caught. If the surgeon's needle caused the damage by inadvertently catching the pelvic floor, it was outside of the operating filed but that was not an event that he would criticise. His hypothesis did not amount to negligence on the part of the surgeon, but that was not why it was his preferred hypothesis: it was because it was a sad fact that no surgeon could control the point of a needle with absolute accuracy 100% of the time. He did not feed into any aspect of his approach to the case the fact that Dr Lingam had no real experience of colposuspension at the time as, on his hypothesis, experience would not be a factor, whereas it could be in the competing hypothesis. The fact that there was bleeding from two distinct areas did not lead him to say that it was therefore more likely that the care was substandard. He could not offer a logical connection between the two areas of blood loss, but they were distinct in the sense that Dr Hassan was able to stop the first blood loss but not the second. If there were two areas of arterial damage that did not impact upon his approach to the case. On his hypothesis the major haemorrhaging was caused by the suture immediately after it had gone through the ligament. He did not know if it was the second suture or the first. If, as he had originally thought, the first bleed was venous, he thought it was caused by the suture going into the veins. The bleeding would have been immediate and would have continued unless it spontaneously clotted. As no bleeding was noticed in the area of the ileopectineal line until the suprapubic catheter was inserted that supported the view that the bleeding was arterial. He thought it improbable that the surgeons had not noticed it. Since he could not connect the two episodes of bleeding, the logic had to be that it was two different manoeuvres at the same part of the procedure in the ileopectineal line which caused them. He had no way of knowing if it was the same suture which caused two lots of damage or two sutures which each caused one lot of damage. He did not associate the ileopectineal line with arteries or arterial bleeding, so, if he were forced to accept that there was bleeding from an artery on the ileopectineal line because that was the evidence of the surgeon, then either there was an artery on the ileopectineal line or both surgeons had failed to notice that where the lead surgeon was operating was not on the ileopectineal line. He did not think that the latter was credible, but he accepted that it would be negligent.

[104] On considering Grant's Anatomy Figure 3.29 Mr Jarvis explained that the pelvic floor was the area above the pubic bone. The pelvic wall stemmed from the side of that area and went up the side of the pelvis. The ileopectineal ligament was located in the pelvic wall. The Figure showed the location of the internal iliac artery and its branches some way away from the area of the ligament attached to the wall. Figure 1 in Dr Lingam's article (7/9 of process), which he had not seen before, was a picture showing what the authors termed was damage to the internal iliac artery. He did not have the expertise to interpret the picture and say that the area of damage was quite some distance removed from the pelvic wall. According to the operation note Dr Carty applied sutures to the base of the bladder and the vagina: that target was not consistent with his hypothesis, but Dr Carty's sutures did not stem the bleeding, a fact which did fit in with his hypothesis. The note went on to record "bleeding welling up in the pelvic side wall". If Dr Hassan's description in evidence of the bleeding coming from the pelvic wall were to be accepted that would effectively mean that his hypothesis would have to be rejected because it clearly could not have been coming from the pelvic floor. If, as Dr Hassan said, the bleeding was coming from the urethra, that would take it a long way away from the area of the ligament, but he thought that that did not make sense because the urethra was not lateral to the vagina but the vagina was underneath and lateral on both sides to the urethra. It was not anatomically possible for the bleeding to come from lateral to the vagina and from the urethra. In his opinion the best evidence about where the bleeding was coming from had to be the evidence from the procedure which stopped the bleeding. The suturing was nothing to do with securing the bleeding: it was Dr Urquhart who secured the bleeding. He thought that was because Dr Hassan and Dr Carty were putting sutures in the wrong place, rather that because the vessel had retracted and they could not reach it. Dr Urquhart's evidence supported his evidence about where the damage was coming from as it was not two to three centimetres lateral to the vaginal wall or the vaginal wall or the urethra but further lateral to that point and he believed the vessels in question to be running through the pelvic floor. He postulated that all the damage occurred because of the use of the needle at the ileopectineal ligament, although not necessarily by the same pass of the needle. Dr Hassan was able to stem the flow from the ileopectineal ligament. Having read the transcript of Dr Lingam's evidence, he was not so sure as he had been earlier that the first episode of bleeding was arterial and he now wished to maintain his position that the first bleed was venous. There could have been a delay in the surgeon noticing venous bleeding because it was obscured by the tying of the suture on the right and initially accumulated out of vision, so that it came within the vision of the surgeon only when there was a sufficient volume. Venous bleeding from the ileopectineal line was not usually a very significant amount of bleeding, but venous bleeding from the vaginal wall could be very significant. Another possible explanation for the fact that it was venous bleeding was that the surgeons were not paying attention. In relation to what he had said earlier about the use of the needle, the surgeon could not hold a J-shaped needle in a needle holder obliquely and stitch, but it must be theoretically possible that if he were to turn the needle holder in an oblique way he would get the same result, an oblique insertion.

[105] In re-examination Mr Jarvis stated that his reading of Dr Lingam's evidence was that initially her view was that she was uncertain whether the first bleed was arterial or venous and that she ultimately concluded that it might well have been arterial. There was in his view a development of thought going on through her evidence. He was in doubt about whether Dr Lingam herself was certain in her eventual acceptance that it was an artery. In his evidence Dr Hassan identified a bleed from the ileopectineal ligament itself. Mr Jarvis had never seen an artery in the ileopectineal ligament or a diagram suggesting that there was an artery in it, although he was sure that there were arteries in the underlying bone. If the bleed was from the ligament it was highly improbable that it was arterial because of the basic anatomical situation, Dr Hassan's description of a wee slight bleed, which did not sound like any arterial bleed that he (Mr Jarvis) had ever seen and the ease with which it was stopped.

[106] Reverting to the question of the vaginal sutures, Mr Jarvis explained that there was a J-shaped needle attached to suture material held by an instrument called a needle holder, which he referred to as a clamp. The reason for that was that all needles which were used internally were too small to be held and controlled by the surgeon's fingers. The surgeon manipulated the needle holder, which was about six or seven inches long, to control the needle. When using a J-shaped needle he put the clamp on the downward stem of the J. The clamp consisted of two pieces of metal attached together at a hinge, the hinge being closer to the non-needle end, and at the non-needle end were two hollow circles through which the surgeon inserted a finger or thumb in order to control the hinge. The surgeon's grip was similar to the grip on a pair of scissors. A surgeon placing a suture in the vaginal wall had to have an entry point and an exit point for his needle in the course of making that suture. The entry point, as already stated, was the anterior vaginal wall, meaning the front of the vagina. Usually the needle exited through the lateral vaginal wall, so that its course was through a 90 degrees arc, the purpose of which was to obtain a relatively solid piece of tissue to use as the base of the support of the bladder neck. In colposuspension the surgeon was always trying to cut through the lateral wall of the vagina with his needle. Tanagho advocated a relatively conventional bite for the first vaginal suture but that the entry point of the second suture in the vagina should always be lateral to the first, rather than in the same area as the first, but still coming out of the lateral wall of the vagina. A second clamp (or some similar instrument) was needed in order to pull the needle right through out of the lateral wall. Without such a clamp the needle could project three to five millimetres. If Grant (6/18 of process, p 200, Figure 3.29) drew the vaginal arteries as coming off the internal iliac artery then he wholly accepted that that was something which would occur. If the vaginal arteries were from the uterine artery they would disappear with the hysterectomy. They ran between the lateral vaginal wall and the pelvic wall and then branched as they approached the vaginal wall with a view to supplying blood to the vagina. As a general rule the surgeon never saw these vaginal arteries when doing a colposuspension because they were already in the process of branching and they entered the vaginal wall in its lateroposterior quadrant. He believed that if it were possible to pull the vagina around they could be seen as they were not covered by tissue. It had been suggested that if the surgeon pulled the needle much more laterally than would be usual that could damage the artery, and, while he thought that was theoretically possible, he did not think it was very likely because there was no particular point in such a manoeuvre, but, more importantly, the only way of freeing the J-shaped needle was to pull the blunt base of the J slightly laterally and so the sharp bit was always pointing back at the vagina, not towards the area where the vaginal arteries might be. A straight or curved needle could have done what had been suggested, but he did not see that a J-shaped needle could have done it. The only way in which he could think of what had been suggested having been done was if the surgeon did not take the needle round its curve but just pulled with rather a lot of strength, thus taking out the needle and a patch of vagina attached to it, but that would be quite a strong manoeuvre and he could not seriously propose that anybody would do that; moreover, there was clearly no evidence of a hole being made in the vagina in this case. He thought it was unlikely that if damage had been caused to a vaginal artery by a needle the supervising surgeon would not notice: the action that would be required by the lead surgeon would be so odd that a supervising surgeon ought to see that action and the damage would result in some blood loss prior to spasm and retraction. If a vaginal artery were severed it was capable of bleeding from both ends. In this case Dr Urquhart located one end of the bleeding artery. There were two reasons for the inability of two surgeons to see that severed vessel: first, the limited visualisation because of the pool of blood in which the surgeon was trying to operate, and, secondly, retraction of the artery by contraction of the muscle within its wall. The severed ends of a vaginal artery would retract a distance backwards along the course of the artery. If the severed end of the vaginal portion was still able to obtain blood from below, it would remain as viable muscle within the wall of the artery and could contract towards the vagina. The other end of the severed artery would retract backwards towards its origin, in the direction of, but not as far as, the pelvic side wall. Dr Urquhart did not block an artery where blood was coming upwards or laterally, so the hypothesis that the cut vessel was a vaginal artery with its collateral circulation would not totally fit with his actions. His action would have stopped the bleeding from only one end, namely, the lateral end coming from the pelvic side wall towards the vagina: it would not have stopped the bleeding coming from below upwards. If the bleeding point was about 3 centimetres from the pelvic side wall and about 4.5 centimetres from the vaginal midline then it was really quite a way lateral from the vaginal fornix, about 3.5 centimetres. In the context of a colposuspension 3.5 centimetres lateral from the edge of the vaginal wall would be a very long way for the surgeon to go adrift and it was not the sort of distance that he would expect a supervising surgeon to miss. He would expect the supervising surgeon to intervene by either the use of words or by placing a hand on the trainee's operating hand.

[107] Returning to his own hypothesis of bleeding from a vessel buried in the pelvic floor, he thought that when Dr Hassan referred to trying to put stitches in the deep pelvis he meant the pelvic floor or towards the pelvic floor, as opposed to the vaginal fornix, which was not the pelvis. The risk of catching an artery contained within muscle was not unique to colposuspension: it was a complication of all surgery which was not surface surgery (surgery on the skin). He was sure that every surgeon understood that that risk existed. He expected that in the literature there would be some estimate of the frequency of significant haemorrhage, but he did not expect it to be specific about whether it was arterial or venous. He did not implicate the pursuer's previous hysterectomy, her BMI of 34 or Dr Lingam's lack of experience in causing her major bleed.

The applicable law
[108] It was accepted that the test which fell to be applied to determine whether there had been medical negligence was that laid down by Lord President Clyde in the well known case of Hunter v Hanley 1955 SC 200, namely, that the pursuer had to prove that the doctor in question was guilty of such failure as no doctor of ordinary skill would be guilty of if acting with ordinary care. In order to establish liability where it is alleged that there has been a deviation from normal medical practice the pursuer must prove (i) that there was a usual and normal practice; (ii) that the doctor had not adopted that practice; and (iii) that the course which the doctor adopted was one which no professional man of ordinary skill would have taken if he had been acting with ordinary care (per Lord President Clyde at p 206 in Hunter; Maynard v West Midlands Regional Health Authority [1984] 1 WLR 634; Sidaway v Governors of Bethlem Royal Hospital [1985] AC 871; and Bolitho v City and Hackney Health Authority [1998] AC 232). Expert evidence falls to be tested according to the criteria in Bolitho. It follows from the second leg of the test in Hunter that where there are competing bodies of medical opinion in relation to matters of medical or surgical practice it is not for the court to prefer one to the other. The law is summarised by Lord Hodge in Honisz v Lothian Health Board [2006] CSOH 24.

[109] The fact that Dr Lingam was a surgeon in training and the fact, according to the pursuer, she lacked relevant recent experience, were not relevant in applying the test. The standard of care expected of an inexperienced doctor learning a surgical procedure is the same as that of an experienced doctor of her grade. To that extent the standard of care expected is objective: Wilsher v Essex Area Health Authority [1987] 1 QB 730 per Mustill LJ at pp 750E-751D and Glidewell LJ at p 774A-E. Although the decision of the Court of Appeal in that case was reversed by the House of Lords no criticism was made of the approach taken by the Court of Appeal to the test to be applied.

[110] It was submitted on behalf of the pursuer that if the court accepted Mr Jarvis's hypothesis or was unable to make a finding about the manner in which the arterial damage was caused a prima facie inference of negligence had in any event been raised which the defenders had failed to rebut. Cases such as Ratcliffe v Plymouth & Torbay Health Authority 1998 Ll L R (Med) 162, Bovenzi v Kettering Health Authority [1991] 2 Med LR 293 and Hendy v Milton Keynes Health Authority (No 2) [1992] 3 Med LR 119 supported the proposition that if an occurrence was not a known complication of a medical procedure or was so rare, that itself could support an inference of negligence. If the court were to accept that arterial damage was not a known complication of colposuspension and should not occur in the exercise of reasonable care, it was submitted for the pursuer that the defenders had failed to rebut the inference that reasonable care was not exercised. In any event, even if it was not possible to go that far, it was submitted that because of the rarity of such an occurrence, the chances of an innocent explanation became very slight and the burden on the pursuer was more easily discharged (Brooke LJ in Ratcliffe).

Discussion and conclusions
[111] The following points were made on behalf of the pursuer in an effort to focus on the critical issues. First, there was no dispute that the second and significant source of blood loss was from a branch of the internal iliac artery. Secondly, in light of the evidence of Dr Brown and Mr Jarvis, there were two live hypotheses as to how the damage occurred. According to Dr Brown it occurred when Dr Lingam moved out of the operating field to some extent while applying sutures to the vaginal wall. Mr Jarvis's final position was that it occurred when a suture was being applied to the ileopectineal ligament and the needle penetrated a muscle in the pelvic floor and damaged an artery. That explanation was not focussed by the defenders n Record and the explanations put forward by the defenders at p 17D-E of the Record had not been supported by expert testimony. Thirdly, Mr Jarvis accepted in his evidence that for the surgeon to move outwith the operating field while applying sutures to the vaginal wall and so to damage the artery would be negligent: it followed that if it were to be found that the damage had been so caused there was no dispute between the expert witnesses that that would constitute negligence.

[112] The submission for the pursuer was that she had proved that the massive haemorrhage had occurred because Dr Lingam moved outwith the operating field when applying the second suture and in so doing caused the damage to a branch of the internal iliac artery. If that were so then, in light of the evidence of Dr Brown and Mr Jarvis, that she fell below the standard of care to be expected of the reasonably competent senior registrar.

[113] It was further submitted for the pursuer that Dr Lingam lacked the necessary recent experience to carry out the colposuspension operation on the pursuer as lead surgeon. Although Mr Jarvis had in his report (7/10 of process) supported Dr Lingam in carrying out the operation as lead surgeon, it was clear after his evidence that he had been under a misapprehension about the nature and extent of her experience in colposuspension. The fact that she lacked the necessary experience might not in itself mean that there had been negligence in the way in which the operation had been conducted, but it was a relevant consideration to have in mind when deciding what inferences could be drawn from the problems that occurred in the course of the operation.

[114] There was no dispute between the experts that Dr Hassan had a duty to supervise Dr Lingam and it was submitted for the pursuer that he had failed in that duty in two respects. First, he had failed to investigate with her the extent of her experience. Secondly, he had failed to supervise her adequately during the operation. It was contended for the pursuer that a combination of inexperience and lack of supervision had conspired to create a situation of unnecessary risk for her.

[115] The submission for the defenders was that the cause of the major haemorrhage was a suture needle snagging an artery in the pelvic floor and that, as any surgeon, however careful, could catch a blood vessel on the pelvic floor during colposuspension, this did not amount to negligence on the part of Dr Lingam. Dr Lingam was sufficiently experienced to undertake the operation on the pursuer as lead surgeon if she was supervised by Dr Hassan. Dr Hassan was not negligent in allowing Dr Lingam to perform the operation as lead surgeon under his supervision. There was no reason to conclude that the massive haemorrhage suffered by the pursuer was caused by any inexperience on the part of Dr Lingam. If the court accepted the cause of the major haemorrhage which the defenders suggested, there was no negligence on the part of Dr Lingam or her supervisor Dr Hassan and, in any event, even if there was negligence on the part of Dr Lingam, there was no evidence that this was a matter which her supervisor (a) could have seen was about to happen; or (b) could have seen had happened.

[116] I now turn to consider each of the alleged heads of negligence.

(i) Dr Hassan's allowing Dr Lingam to perform the colposuspension

[117] I have set above at para 6 Dr Lingam's experience in colposuspension before she performed as lead surgeon under the supervision of Dr Hassan the operation on the pursuer. Both Dr Brown and Mr Jarvis agreed that there was a duty on Dr Hassan to have questioned Dr Lingam on her previous experience, in particular in carrying out colposuspensions, and that he failed in that duty. Dr Hassan in his evidence in effect accepted that he carried out an inadequate inquiry. According to him, he asked her what colposuspension operations she had done and she said that she was interested in urogynaecology, she had worked in the Urology Department and did colposuspension operations. He did not think that she gave any indication as to how many colposuspensions she had previously done, and indeed it was his view that it was not relevant for him to know how many she had done "because once she said she had done and she's competent, I just take her word". He was under the impression that she had done colposuspensions at the Royal Infirmary before coming to the Southern General Hospital and he thought "if we've got somebody who's a senior registrar who's interested in gynaecology and doing a urogynaecology job in a Urology Department, I'd be satisfied with that if she told me that". He accepted that he did not know when she was working at the Royal Infirmary or for how long she had worked there. He then said that he "asked her just before coming to us, so she came straight to the Royal from us, so these are recent experience" (sic).

[118] It is in my opinion quite clear from the evidence that, before he allowed Dr Lingam to operate on the pursuer (and also on the patient before her) Dr Hassan had no clear idea about the nature of her experience in doing colposuspensions and how recent it was. He did not know how many colposuspensions she had carried out as lead surgeon and when she had done them. It was accepted on behalf of the pursuer that he might have been to some extent misled by what Dr Lingam told him, but submitted that he did not go far enough to satisfy himself about the extent of her recent experience. I accept that that is the case. At one stage in his evidence Dr Hassan went as far as to say "I expect her to be a skilled surgeon, otherwise she wouldn't be a senior registrar". In my view that reply shows that he made an unfounded assumption about her experience and surgical ability. When Dr Lingam's actual experience was put to Dr Hassan he expressed the view that if in the previous five to six years she had done only one colposuspension as lead surgeon that might suggest that she lacked recent experience but did not mean that she would not be able to do the procedure and he would not allow someone with that experience to do the operation on her own with a junior person, only if a senior person would be with her in theatre. It was his view that it was appropriate that she should act as lead surgeon, but only with a more senior assistant.

[119] The evidence of Dr Brown was that Dr Hassan was not entitled to accept at face value Dr Lingam's statement that she was experienced: it was his opinion that he required to ask her questions about her colposuspension experience, when she had done colposuspensions, how many she had done, where she had done them, and what was her past and recent experience. In his view the detail of her experience could not be taken for granted. Dr Brown's interpretation of Dr Hassan's evidence was that Dr Hassan had been acting under a misapprehension about her experience and had assumed that because she was a fifth year trainee she had up to date experience. When Mr Jarvis wrote his report he stated that Dr Lingam was a wholly appropriate surgeon to perform the procedure but when he expressed that opinion he was proceeding on the basis of a report from her dated 14 October 2002. I do not know what the precise contents of that report were, but it appears from the evidence of Mr Jarvis that it did not disclose the details of Dr Lingam's experience as spoken to by her in evidence. It was the position of Mr Jarvis that when he wrote his report he understood that Dr Lingam had greater experience than she had. He considered it to be the duty of the supervisor, before giving Dr Lingam a whole procedure to do as lead surgeon, to satisfy himself that she had appropriate recent experience with the procedure. His evidence on this point is set out in full at para XX above. In my opinion the burden of that evidence is that, had he been the supervisor and known the true position about Dr Lingam's experience he would not have allowed her to carry out as lead surgeon the operations on the pursuer and the previous patient.

[120] In light of the evidence of Dr Lingam, Dr Hassan, Dr Brown and Mr Jarvis on this point, I am satisfied that Dr Hassan, before allowing Dr Lingam to carry out as lead surgeon the colposupension on the pursuer was under a duty to satisfy himself by appropriate inquiry that she had sufficient recent experience of the procedure and that he failed in that duty and was therefore medically negligent to that extent. That failure in duty by Dr Hassan did not, of course, cause the pursuer's injury but it is clearly a relevant background against which to consider the events which occurred at the operation. The same comment applies to the substantive fact that Dr Lingam lacked the required recent experience to act as lead surgeon.

(ii) The performance of the colposuspension by Dr Lingam

[121] The central question which I have to determine is whether Dr Lingam was professionally negligent in her performance of the colposuspension. There were, as mentioned above, two separate sources of bleeding noticed in the course of the operation. It does not, of course, necessarily follow that the first bleed to have been noticed was the first which occurred. It is not suggested that the first source, which was associated with the ileopectineal ligament, caused or contributed to the neurological injury suffered by the pursuer for which she seeks damages and its relevance is therefore limited. The point made on behalf of the pursuer was that the fact that it occurred could assist in relation to the expertise displayed by Dr Lingam in the course of the operation, particularly if the source was arterial.

[122] It was Dr Lingam's evidence that the procedure which she undertook was not a Burch colposuspension but the Tanagho modification, which to her meant that a different number of sutures were used in different positions from the Burch method. She described the procedure in full in her evidence. She explained that her first suture to the vagina would be slightly medial, just lateral to the urethra in order to support the bladder neck and that the second stitching must be as lateral as possible to support the proximal urethra without obstructing it. In applying her sutures to the vagina she would not pick up or use the paraurethral tissue and she would place two sutures on each side, one medial and the other as lateral as possible. She said that she placed her lateral suture in the vaginal wall and the position of her suture in the ileopectineal ligament was largely determined by the position of the vaginal suture below it. She was aware that if she went too laterally on the ligament damage could be caused to blood vessels running down the side of the pelvic wall and that this risk was avoided by visualisation of the ligament and the pelvic wall. Dr Hassan's evidence was that he saw Dr Lingam place two sutures in the right wall of the vagina and he had then no concern that there were in any way being placed inappropriately. There was no immediate bleeding when they were placed and no other sign that any damage had been caused. He saw Dr Lingam insert the sutures in the ileopectineal ligament and had no concern that those sutures were in any way being placed inappropriately. There was no immediate bleeding from the ileopectineal ligament and no sign of any other damage to it. There was no sign of bleeding when the vagina was elevated and the sutures tied or during the removal of the Foley catheter and the placement of the suprapubic catheter, a process which usually took between 10 and 15 minutes. It was only after the suprapubic catheter was inserted and it was being checked that it was safe to close the abdomen that bleeding was noticed. It appeared initially to be a little bleeding from the right side, more significant than the bleeding normally seen. It then came up out of the abdomen into the wound, overflowing the pelvis. He took over and cut the stitches but blood was still welling up out of the pelvis into the abdominal wound. Suction was applied and swabs used to see if the bleeding could be controlled. He saw bleeding in the ileopectineal ligament, which he described as "wee slight bleeding from there", put a stitch on it and the bleeding stopped altogether. He said he thought this bleed most probably occurred because the needle went through the ligament and must have pierced a vessel. He could not see any vessel in the ligament and usually there were no blood vessels there. In his view Dr Lingam had not gone too far laterally and had been in the medial part of the ligament.

[123] Dr Lingam accepted that the initial source of blood loss was active blood loss which was not normal and, at least at one stage in her evidence, that it was arterial. According to the operation note that blood loss was stemmed by the application of sutures by Dr Hassan and according to Dr Hassan himself only one suture had to be applied.

[124] It was Dr Brown's view that the source of this first bleed was arterial and that the bleed had been caused because Dr Lingam had gone too far laterally when placing the second suture and so damaged a branch of the inferior epigastric artery. He suggested that Dr Lingam's attempt to insert a suture in the right ileopectineal ligament failed so that she missed the ligament completely and that she inserted the suture into a fatty pad of tissue or onto the pelvic side wall, both of which structures might incorporate blood vessels. Mr Jarvis, having read Dr Lingam's evidence (in which she clearly vacillated about whether the first bleed was venous or arterial) expressed the view that it was venous. There would be no delay in a venous bleed appearing.

[125] Dr Brown's view on this point was subjected to strong criticism on behalf of the defenders. It was submitted that the factual basis for his view was clear, that his view did not meet the evidence given and that to accept it would involve rejection of the evidence given by Dr Lingam and Dr Hassan regarding a matter upon which they were not challenged. It was at best an inference or hypothesis seeking to explain the presence of blood on, but not coming from, the ileopectineal ligament and assumed significant, rather than merely trivial or incidental, blood loss. It did not explain why a suture or sutures placed by Dr Hassan in the ileopectineal ligament stopped the bleed. Dr Hassan attached no particular significance to this bleed, which he said he stopped easily. It had not been suggested to Dr Hassan that he had sutured a vessel in the fatty pad or pelvic side wall to stop the bleed: he said that the blood was coming from, and that he sutured, the ligament. As Dr Hassan's suture or sutures to the ligament stopped the bleed, the natural inference was that the bleeding vessel was associated with the ligament itself. The evidence of Mr Jarvis was that bleeding from the ligament requiring suturing occurred in 5% of colposuspensions and that it was normal and not problematic. Dr Brown accepted that his view could not be correct if the blood was coming from the ligament and that it could not explain why Dr Hassan would be able to stop the bleeding by suturing the ligament. In any event, according to Mr Jarvis the view of Dr Brown contained an internal inconsistency. The evidence of Dr Lingam and Dr Hassan was that the sutures were tied without problem, thereby elevating the vagina in the desired manner, and that they remained tied until cut down by Dr Hassan to facilitate investigation of the haemorrhage. Dr Brown's mechanism required that during the tying of the right lateral suture sufficient force was applied to the artery to tear it. That in turn meant that the two ends of the suture must have been sufficiently anchored so that the artery was, in effect, the weakest point, but missing the ileopectineal ligament and suturing through a fatty pad or into the pelvic wall would not have provided a secure anchor because when the surgeon tried to tie the suture it would cut out of the tissue. Dr Brown's view could therefore not explain how the suture could be tied or be effective in elevating the vagina. It was inherently unlikely that Dr Lingam missed the ileopectineal ligament with the right lateral suture because (a) the principle underlying colposuspension, and common to its variants, was elevation of the vagina and its attachment to the ileopectineal ligament; (b) Dr Lingam had experience of the procedure, albeit little recent experience; (c) Dr Hassan was an experienced trainer in the procedure and was watching where Dr Lingam was placing the sutures; (d) the ileopectineal ligament was distinct in appearance from fat and from the pelvic wall and could not easily be confused with them; (e) missing the ileopectineal ligament with the suture ought to have been apparent to both Dr Lingam and Dr Hassan; and (f) neither Dr Lingam nor Dr Hassan considered that the suture had been placed other than in the ligament, although they differed about whether it had been placed laterally or medially. Accordingly, there was no reason to conclude that Dr Lingam had missed the ileopectineal ligament completely and damaged a blood vessel in the fatty pad lateral to the ligament or in the side wall of the pelvis: the more likely explanation was that the bleed was merely incidental to Dr Hassan cutting the sutures to secure a view of the more serious bleeding.

[126] In my opinion there is considerable force in this submission for the defenders, which is really unanswerable. Having considered the whole evidence on this point, I find that I am unable to make any finding about whether the source of this first bleed was venous or arterial. It therefore follows that the pursuer has failed to establish that it was arterial. The delay in the bleed being noticed points to its being arterial, but the fact that it was stemmed by the suture or sutures applied by Dr Hassan points to its being venous. Further, in light of the criticisms of Dr Brown's view on this point set out in the above submission for the defenders, I do not accept the evidence of Dr Brown about how this bleed occurred. I am not persuaded that the bleed was merely incidental upon Dr Hassan cutting the sutures to secure a view of the more serious bleeding, but I do not require to make any finding about what caused the bleed. It was for the pursuer to prove that it was caused in the way suggested by Dr Brown and she has failed to do so. It follows that I make no finding of professional negligence against causing Dr Lingam in relation to this first bleed.

[127] So far as the second bleed, the major haemorrhage, is concerned, it is agreed in a joint minute that this was from a branch of the internal iliac artery. The internal iliac artery is the principal artery supplying blood to the pelvis. It divides into a large number of branches as it enters the pelvis. These branches may be found throughout the pelvis. The source of this haemorrhage could not be identified during the attempts to halt it in theatre. The only factual evidence about its source came from the intervention radiologist Dr Urquhart, who located the bleeding artery by radiological imaging and performed vessel embolisation on the pursuer and succeeded in stopping the haemorrhage. He confirmed, with the assistance of the photograph in the article which 7/9 of process, that the vessel in question was a medial branch of the internal iliac artery. He said that it was halfway between the midline and the lateral bony wall of the pelvis and to calculate the bleeding point as being about 3 centimetres medial to the side wall of the pelvis and about 4.5 centimetres from the midline. According to him the anatomy of the internal iliac artery is quite variable, particularly in a patient with previous multiple operations, and it was not really possible to say which anatomically named artery it was, if it had a name. Under reference to Grant's Anatomy Figure 3.29 (6/18 of process) he said there was no way of being definite about what branch of the internal iliac artery the vessel was, particularly as the pursuer had undergone major gynaecological surgery. A number of relevant organs had already been removed and the arteries supplying them tied off. In his view new arteries would have opened up to supply the tissues within the pelvis. The vessel might not even have been a normal branch. It appeared to be roughly in the area where the uterine artery and the vaginal arteries were shown in the Figure. He could only speculate that that it was situated in the region of the arteries that would have supplied the vaginal vault and whatever tissues were left following upon the previous surgery. It could not have been the uterine artery as it would have been tied off at the time of hysterectomy, but it was roughly where you would expect to see the uterine artery. He suggested that the artery might have been part of a collateral blood supply that developed after the hysterectomy and that its position would not necessarily be anticipated by a surgeon. In this type of patient he did not expect the arteries to correspond to any textbook picture and it was possible that the pursuer's vessel anatomy was unique.

[128] Dr Lingam said that her reference in the operation note to "the deep pelvis and lateral vaginal fornix" was a reference to the general area of the vaginal arteries as shown in Grant's Anatomy, Figure 3.29. Mr Jarvis accepted that the reference to the "vaginal fornix" was unhelpful to his hypothesis and he relied on the reference to "the deep pelvis" to support his hypothesis that an artery in the pelvic floor was the source. In cross-examination Dr Lingam agreed that she could not say from where precisely within the pelvis the bleeding was coming from, and in re-examination stated that she would not say that the source "was most definitely the vaginal artery" but that at the time of the operation that was where the blood was coming from.

[129] Dr Hassan's evidence was that he focussed on the general area of the vaginal wall side of the operation. He said that the bleeding was coming from an area where the stitches had been put in the vaginal wall, from the urethra. In cross-examination he said he said that he "realised stitching this sort of vaginal area was not going to stop the bleeding" and he called Dr Carty. He also said that it was very difficult to locate how far from the area they were operating in the medial branch of the internal iliac artery was. Mr Jarvis accepted that the fact that efforts to staunch the blood were targeted towards the area of the bladder and the vagina was not consistent with his hypothesis but contended that, as the bleeding was not controlled, that might suggest that the chosen target area was incorrect. On the other hand, it is likely that the surgeons present at the time would target the area where they saw the blood coming from, and there is the possibility that the severed artery would have retracted, making identification difficult.

[130] Dr Brown thought it likely that Dr Lingam had caught some non-vaginal tissue in the suture to the lateral vaginal wall and that that tissue incorporated the branch of the right iliac artery and subsequently caused the haemorrhage. It was his opinion that arterial bleeding should not occur in the course of a colposuspension because the surgeon should not go into an area where there was a risk of arterial bleeding. He accepted that, while venous bleeding was to be expected because the area in which the surgeon was operating was a very vascular area, arterial blood loss was not to be expected because the surgeon should not be operating in an area where damage to an artery might be caused: arterial damage reflected substandard performance by the surgeon. Mr Jarvis thought that the most likely cause of the major haemorrhage was that Dr Lingam's needle had caught a branch of the internal iliac artery buried in the floor of the pelvis while she was suturing the ileopectineal ligament. It was his view that, however careful the surgeon may be, there was always some risk of this happening. The needle, which was controlled by the surgeon using the needle-holder or clamp, had to be inserted through the ligament and twisted round. It was submitted for the defenders that injury to a vessel positioned in the pelvic floor was consistent with the evidence of Dr Urquhart about the location of the embolised vessel and the inability of the surgeons to find the bleeding point. It was contended that Dr Lingam's insertion of the needle in the right ileopectineal ligament would have been her last insertion and that that went some way to explaining the delay in the bleeding being apparent.

[131] I am satisfied on the evidence which I have heard that arterial bleeding is not an accepted or recognised risk of colposuspension. No evidence was produced from the medical literature to show that it is a recognised risk. If it were a recognised risk then I have no doubt that, because of the serious and potentially fatal consequences which could flow from its occurrence, it would have been not only mentioned but also emphasised in the medical literature dealing with the subject. Mr Jarvis, although unable to cite any reference in the medical literature to the risk of arterial damage in the course of colposuspension, mentioned his personal experience of one colposuspension in which he damaged an obturator artery. It seems to me that this evidence shows that arterial damage is indeed exceptional case because it was the only case of arterial damage which Mr Jarvis was able to cite from his long career, and, moreover, he was able to explain how it came about in the absence of negligence. The only other reference in evidence to a case of possible arterial damage as the mention by Dr Hassan of a case in Ireland in about 1986, but there are no details available about the nature of that bleed and how it was caused and I therefore do not think that much can be made of that evidence.

[132] As arterial bleeding is not a recognised risk of colposuspension, it is next necessary to ask what the cause of the arterial bleeding in this case was. I have summarised above the hypotheses proffered by Dr Brown and Mr Jarvis on the location of the arterial bleed. Dr Brown thought that the damage to the arterial branch was caused while Dr Lingam was working in the vaginal area and that, when applying her lateral suture there, she moved into the area of the vaginal arteries. He suggested that the delay in the appearance of the haemorrhage was because in placing the second and more lateral suture Dr Lingam went round and traumatised an artery and the damage was caused when the sutures were elevated. He accepted the theory of arteries going into spasm and retraction and stated that there would be some initial bleeding at the time the transaction occurred and before spasm and retraction. Dr Brown thought that Mr Jarvis's hypothesis that the haemorrhage occurred when the bladder was reflected was highly unlikely as bleeding at that stage in the procedure was always venous. When asked when the damage to the artery could have been caused, Mr Jarvis said it could have been either when Dr Lingam was placing a suture into the ileopectineal line or into the vagina and that it would be pure speculation to confirm one or the other. He had difficulty with the concept of there being an artery near to the lateral vaginal wall because in his opinion the blood supply to the vagina came in two directions - upwards and downwards from what would have been the uterine artery supplying the uterus, but that following a hysterectomy the uterine artery was divided and ligated and all the blood supply to the vagina after a hysterectomy was coming upwards from the area of the vulva. That was an important consideration for him in rejecting the idea that the haemorrhage was from an artery near to the lateral vaginal wall. In cross-examination, after looking at Grant's Anatomy, he agreed that the vaginal arteries were displayed as arising from the internal iliac artery itself and that his objection based upon the direction of the blood supply was not valid.

[133] When Mr Jarvis wrote his report and also when he began giving evidence he was not aware that Dr Lingam had placed her sutures as far laterally as possible in the vaginal wall. He accepted that he could understand how a surgeon could misjudge the vagina but not the ileopectineal line. He initially said he could not visualise how a suture placed in the lateral wall of the vagina could make contact with a branch of the internal iliac artery but later, in cross-examination, after being referred to Grant's Anatomy, he accepted that this was possible and that, if it happened, it would constitute substandard care. He agreed that Dr Brown's hypothesis was a possible explanation but was not prepared to accept that it was more likely than the explanation which he himself advanced.

[134] It was submitted for the defenders that there were problems with Dr Brown's hypothesis. It was Dr Brown's view that when Dr Lingam placed her more lateral suture she either went round or traumatised an artery and the damage occurred in the process of the suture being tied. He revised his view of the scope for arterial damage by stretching in the course of his evidence. He initially discounted stretching of the artery as a likely factor but subsequently incorporated it into his mechanism. It was therefore not his initial explanation for the haemorrhage. He was not aware of seeing arteries as such in the area of the vaginal wall. The style of colposuspension which he performed meant he did not operate in that area. He had no experience of performing, or even of being present during, a Tanagho colposuspension. He had not himself seen the area and was not sure what tissue it might contain. He accepted that he was speculating that there would be something in the area to catch with a suture and his view appeared to have been based upon an interpretation of an anatomical diagram in Grant's Anatomy. His explanation depended upon both Dr Lingam and Dr Hassan having failed to notice that some additional unintended tissue containing the blood vessel had been gathered in the suture. This failure would have to have persisted from the point the needle was passed through the tissue and there would have been an opportunity to notice that this had happened up to the point in time at which the suture was cut. Neither Dr Lingam nor Dr Hassan noticed anything despite the fact that the vaginal wall was distinct in colour from the surrounding tissues. It was the view of Mr Jarvis that it would be very difficult to fail to notice that adjacent tissue had been pulled into a suture, and he dealt in detail with the suturing mechanism in re-examination. He found it difficult to see how the needle could have been withdrawn from the lateral wall of the vagina with its tip lateral to the vagina so that it caught the artery. From the radiological position of the embolised vessel as spoken to by Dr Urquhart the distance which the tip of the needle would have to have travelled lateral to the vaginal wall was of the order of two centimetres, and in the view of Mr Jarvis this was too great a distance for an experienced supervisor to have failed to have noticed.

[135] The following criticism was made of Mr Jarvis in the submission for the pursuer. Notwithstanding that, unlike Dr Brown, he had had access to the surgeons who had operated, he proceeded on the basis of a number of assumptions about how Dr Lingam had carried out the operation. He had assumed that she had carried out the operation in the same way that he himself would have done, whereas in fact the way in which he would carry it out differed in a number of respects from the way in which she carried it out. He was not aware that she would seek to go as far laterally as possible with her second sutures to the vaginal wall and the ileopectineal ligament. In order to maintain his hypothesis he essentially sought to ignore the eyewitness accounts of the bleeding from Dr Lingam and Dr Hassan. If Dr Brown's evidence about the location of the haemorrhage were to be accepted, then Dr Jarvis's hypothesis was wholly undermined. In his report Mr Jarvis postulated two possible causes for the haemorrhage, namely, the initial part of the dissection involving the dislocation of the bladder and that a needle used in placing a suture into the ileopectineal line inadvertently caught a blood vessel in the floor of the operating field. In his report he said "I have no way of knowing which of these two was the more likely scenario". In evidence in chief he initially said that the damage could have been caused by placing a suture into either the ileopectineal line or into the vagina, but then went on to indicate that he had difficulty with it being an artery near the lateral vaginal wall because the blood supply to the vagina following upon a hysterectomy came upwards from the area of the vulva. In cross-examination he said he could not visualise how a suture placed in the lateral wall of he vagina could make contact with the artery. It was only on being referred to Grant's Anatomy that he accepted that that view was not valid and that the vaginal artery could be injured with a suture as it came out of the lateral vaginal wall, while contending that that was no more likely an explanation than his hypothesis. It was submitted that these references showed that Mr Jarvis was not wholly consistent in his approach to what caused the haemorrhage. In re-examination he gave detailed evidence about how he would carry out suturing to the vaginal wall, in relation to which two points could be made. First, Dr Lingam was not asked about how precisely she would apply the sutures using the J-shaped needle and, in particular, whether her approach was the same as that of Mr Jarvis. Secondly, it was never suggested to Dr Brown in cross-examination that the manipulation of the J-shaped needle would be such that it could not be pointed towards the artery adjacent to the vaginal wall. That suggestion was made by Jarvis only in his re-examination. He also raised in his re-examination the possibility of some bleeding from the other end of the dissected artery and appeared to make the point that Dr Urquhart required to deal with only one bleeding end rather than two. This matter was never put to either Dr Brown or Dr Urquhart for their comments.

[136] I have not been persuaded by the hypothesis put forward by Mr Jarvis for the cause of the arterial damage. In my view the criticisms of his evidence made in the submission for the pursuer are well-founded. I consider that his hypothesis was far fetched and unsupported by the evidence. I think that in coming to his view he placed too much reliance on the reference to the pelvic wall in the operation note and that he in effect left out of account the reference to the vaginal fornix. I also think that his evidence failed to take sufficient account of the evidence of Dr Lingam and Dr Hassan about where they considered the haemorrhage to be coming from. Further, I take no account of his evidence about the use of the needle given in re-examination. This was the first time this point was raised in evidence and it would be quite unfair to the pursuer for me to take it into account to any extent. Had this matter been considered to be of any significance by the defenders it should have been put to Dr Lingam, Dr Hassan and Dr Brown. As matters stand I do not know what their evidence on this point would have been.

[137] Although the rejection of Mr Jarvis's hypothesis does not automatically result in the acceptance of that of Dr Brown, I have reached the conclusion that the probability is that Dr Brown was correct in his evidence about how the haemorrhage came about, for the following reasons. First, as I have found above, arterial damage is not a recognised complication of colposuspension. Secondly, I think that it is not without significance that an arterial bleed occurred in the course of a colposuspension being carried out by a trainee surgeon who lacked recent experience of the procedure. Thirdly, Dr Brown's view is consistent with the evidence of Dr Lingam and Dr Hassan about where the haemorrhage appeared to be coming from. Fourthly, Dr Urquhart's evidence is consistent with initial damage in the area of the vaginal wall and inconsistent with damage to an artery located in the pelvic floor.

[138] In any event, following upon my finding that arterial damage is not a recognised complication of colposuspension and in light of the authorities referred to above, as well as Cassidy v Ministry of Health [1951] 2 KB 343, I am of the opinion that, once arterial damage has been proved by the pursuer, that raises a prima facie inference of negligence on the part of the defenders which it is for them to rebut by acceptable evidence. There has been no such evidence in this case. It is sufficient for the pursuer to show that she suffered arterial damage without proving precisely how that occurred: it is then for the defenders to prove that it occurred without negligence on their part. In Cassidy Denning LJ (as he then was) said that a plaintiff is entitled to say: "I went into hospital to be cured of two stiff fingers. I have come out with four stiff fingers, and my hand is useless. That should not have happened if due care had been used. Explain it, if you can." Similarly, in my opinion the pursuer in this case is entitled to say: "I went into hospital to undergo the routine operation of colposuspension. I have come out with a neurological injury which was caused when a branch of my internal iliac artery was damaged during the operation. That should not have happened if due care had been used. Explain it, if you can." In my judgment the defenders have failed to explain how the pursuer sustained her injury without negligence on the part of the operating surgeon.

(iii) Dr Hassan's supervision of the operation by Dr Lingam
[139] It follows in my opinion from my foregoing findings that he must have been negligent in his supervision of the performance of the operation by Dr Lingam. Had he been exercising reasonable care in his supervision of her she would not have been allowed to execute the manoeuvre which caused damage to a branch of the internal iliac artery and the pursuer's consequent neurological injury. What I find remarkable in this respect is that he thought that Dr Lingam was carrying out a Burch colposuspension when in fact she was carrying out a Tanagho modification.

Decision
[140] I shall repel the pleas-in-law for the defenders, sustain the first plea-in-law for the pursuer and award damages in the agreed sum of £40,000. No formal interlocutor will be pronounced until the questions of interest and expenses have been determined at a By Order Hearing.

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	Scottish Court of Session Decisions
You are here: BAILII >> Databases >> Scottish Court of Session Decisions >> Greenhorn (AP) v South Glasgow University Hospitals NHS Trust [2008] ScotCS CSOH_128 (05 September 2008) URL: http://www.bailii.org/scot/cases/ScotCS/2008/CSOH_128.html Cite as: [2008] CSOH 128, [2008] ScotCS CSOH_128

Scottish Court of Session Decisions