MPS cases
The danger of the casual aside
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Mr J, a 28-year-old teacher, called his local OOH
service one evening complaining of vomiting and
diarrhoea, some abdominal pain and dysuria.
He had just returned from the cinema with his wife
and the symptoms had come on during the film.
No relevant PMHx and no other meds.
Vomiting was getting worse and he was unable to
attend the centre, so a visit was arranged and Dr A
called to see him at home that night.
The danger of the casual aside
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Dr A examined him.
Mr J was afebrile, had a soft abdomen with
suprapubic tenderness but no signs of guarding or
rebound.
Urine dip - 2+ leucs + protein
Provisional Dx of UTI.
Prescribed course of ABx with simple analgesia,
recommending that Mr J should see his own GP if
things did not improve.
No record of time frame for this.
Happy with Mx so far?
The danger of the casual aside
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Mr J’s own GP, Dr C, was in the middle of a busy
afternoon surgery 2 days later.
Mr J’s wife was attending a routine appointment
with him to get a repeat prescription for OCP +
Ax of chronic eczema.
No mention of her husband’s problems until the
end of the consultation, when she stood up and
handed over the record of Mr J’s OOH contact.
The danger of the casual aside
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At this point Mrs J claimed that she informed Dr C
that her husband still did not feel any better and in
fact she was now frightened that he might have
appendicitis.
She reports that during the exchange that followed
Dr C advised her to “give the tablets time to work”.
Dr C, however, made no record of this conversation
and had no memory of Mrs J giving such detailed
information, or indeed that she was so concerned
about her husband’s condition.
What would you have
done?
The danger of the casual aside
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Mr J’s pain and general symptoms persisted. He did
not try to contact Dr C or his own surgery during this
time, but 2 days later he contacted the OOH service
once again, requesting a home visit.
A different doctor assessed him and, based on his
findings and the history, made a diagnosis of
perforated appendicitis and peritonitis, admitting him
to hospital as an emergency.
Mr J subsequently lodged a claim against Dr C.
Learning points?
Expert opinion
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No record made of the conversation between Dr C
and Mrs J at the surgery.
Expert GP opinion advised that if Mrs J had
mentioned she thought her husband may be
suffering from appendicitis, Dr C should at least
have obtained further info about the case + offered a
consultation on that day.
However, as Dr C recalled the conversation with Mrs
J as a brief mention on her departure about an OOH
visit with no specific voicing of her concerns, or that
her husband was still unwell, the experts thought his
actions were reasonable.
Outcome
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MPS defended the case to trial. The
court found in favour of Mr J and
awarded moderate damages.
Learning points
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The “casual aside”, often thrown in at the end of a
consultation and not always at a convenient
moment, has the potential to cause problems.
An exhaustive history is not expected, but safetynetting is essential and should help to protect the
patient and the doctor involved.
When a patient mentions a medical problem to you,
you have a duty to deal with it, but not necessarily
there and then.
Learning points
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A short note of Mrs J's comment might well have
resolved this issue more quickly.
Relying on one's recollection is often hazardous.
Courts have to resolve a conflict of evidence and
may prefer the recollection of a patient, for whom
this was a unique experience, to that of a doctor, for
whom this was one in a series of consultations.
The courts make no allowances for the
circumstances of a consultation, eg, in this case,
where the surgery was very busy.
Wrongly Reassured
Wrongly reassured
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Miss R, 28yrs, stable relationship. Worked shifts in a
call centre, forgetting to take OCP.
Tried IUCD in the past, developed an infection, had
to be removed, not keen on trying again.
After discussing potential options with her GP, Dr F,
decided she would like to try depot.
As part of the consultation and counselling, she was
warned that she could expect some changes to her
vaginal bleeding pattern, particularly during the first
injection cycle.
Happy with Mx so far?
Wrongly reassured
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Attending for 3rd injection, 6m later, she told the
nurse she was getting light PV bleeding at times.
It didn’t cause her distress and she enjoyed the
freedom that the injection gave her, particularly with
her irregular hours, she didn’t have to worry about
setting her alarm to take the pill.
The nurse reassured Miss R, told her that some light
bleeding was common with the injections.
There was no record made of the need for any
further medical review if the bleeding did not stop.
And now?
Wrongly reassured
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Over the next 18 months, Miss R made several
mentions to nursing and medical staff that she was
still having irregular PV bleeding.
There were brief records made of 3 such
discussions. 2 involved discussions between nurse
+ duty doctor at the surgery, at no point was a pelvic
examination undertaken, or any more detailed
gynae Hx recorded.
One entry implied that previous records had not
been looked at by the doctor involved.
How about now?
Wrongly reassured
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Miss R continued with the depot
Nearly 2yrs after the first one, she made an
appointment with Dr F.
The irregular bleeding had never stopped and,
although it had originally only been 3 or 4 times a
month, now it was on an almost daily basis.
Dr F made an appointment for Miss R to have a
cervical smear.
Wrongly reassured
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The smear showed severely dyskaryotic cells and
she was referred urgently to gynaecology.
Miss R had an invasive cervical carcinoma and a
radical hysterectomy was carried out.
Outcome
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A claim was made and expert opinion found
the case to be indefensible.
She successfully sued the practice for a high
sum.
Learning Points
Learning points
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Clinicians managing women with any unusual
bleeding pattern, especially while using
progesterone-only injectable (POI) contraceptives,
should take a full history and conduct an appropriate
gynaecological examination.
While spotting and mild PV bleeding is common in
the 1st cycle of POI, if this becomes persistent, or
the bleeding occurs after a period of amenorrhoea,
then exclude gynae problems that are clinically
indicated.
Learning points
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If the medical notes are available to the
clinician and they are not reviewed for an
ongoing problem, it is very difficult to defend
a claim or complaint.
Having a look at a patient’s previous
attendances can give invaluable clues to
diagnosing a new problem.
It is important to listen carefully to patients’
concerns, especially symptoms mentioned as
a “by the way” comment.
Learning points
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As care is often team-based, involving GPs,
nurses, nurse practitioners, it is essential to
have a protocol in place where anything
untoward is flagged.
Remember the red flags for referral for
gynaecological cancers:
Remember red flags for
referral for gynae cancers:
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Consider urgent referral for persistent IMB/PCB with
a normal pelvic examination.
If lesions suspicious of cervical/vaginal Ca seen on
speculum, smear result is not needed before referral
and a previous negative smear test is not a reason
to delay referral (NICE guidelines).
The 1st symptoms of gynae Ca may be alterations
in menstrual cycle, IMB, PCB, PMB, or vaginal
discharge.
If a pt reports any of these symptoms, the doctor
should undertake a full pelvic examination, including
speculum examination of the cervix.