In 2011, Professor Martin Corbally saw a two and a half year old girl and recommended a minor surgical procedure to stop the frenulum (soft tissue fold) on her top lip from catching. While writing his outpatient notes following the appointment, he referred the girl for surgery to correct an ‘upper lingual frenulum’ instead of an ‘upper labial frenulum’.
When booking the girl in for the procedure, Professor Corbally correctly described the procedure as ‘tongue tie (upper frenulum)’. The patient administration system in use at the time required all frenula dissections to be described as ‘tongue tie’. It did not allow for the words ‘upper frenulum’ to be entered into the system, with the result that the procedure was referred to simply as a ‘tongue tie’.
On the day of the surgery, Professor Corbally was called away to attend to another patient and he delegated the surgery, by reference to the incorrect description on the theatre list, to a specialist registrar. The specialist registrar performed a tongue tie operation. The error was discovered after the surgery and the correct procedure was performed on the same day. The girl made a full recovery and suffered no ongoing disability, but her parents made a complaint of poor professional performance against Professor Corbally.Download PDF