7
Learning from clinical claims in primary care
Dr Peter Mackenzie, head of membership governance at MPS, looks at the reasons why claims in primary care are settled
F diagnostic errors,1
ollowing on from the last edition of Casebook, in which we looked at we are
running a series of articles that provide an overview of why clinical negligence claims are settled. We start by looking at general practice and over the next few issues, we will look at cases across the spectrum of specialties. Almost half of all claims in primary care are able to be defended successfully. If a decision is made that we will be unable to defend a case successfully, we record the reasons why a settlement needs to be made and we have aggregated that information as a guide to common pitfalls in primary care. The top four reasons for settling claims in primary care are set out below in chart 1. Considering each in turn:
Failure or delay in making the correct diagnosis (FTD) We know from a previous MPS study that 50% of delays in diagnosis in primary care relate to surgical conditions, 32% to medical and 18% to obstetrics/gynaecology.2 Malignant neoplasms are the largest category of claims where there was an alleged delay in diagnosis. Of claims brought against UK GPs in 2009, in one in five the allegations related to the investigation, diagnosis or treatment of cancer. Delays in making a diagnosis can arise for a number of reasons, and can involve the actions of the doctor, the patient or the healthcare system itself. Recent articles have looked at issues within healthcare systems, such as the impact of easier access to diagnostics in primary care, particularly in conditions
where early diagnosis can be critical to the outcome, such as oesophageal, pancreatic and bladder cancers.3 Failure to diagnose breast cancer is the commonest cancer claim in general practice, whilst missed rectal carcinoma is the commonest digestive tract claim. Missed breast carcinoma, melanoma and rectal carcinoma make up nearly one third of all cancer claims in primary care. So why do claims for diagnostic problems occur in cancer cases? The most common reason is because there has been a failure to consider referral or to perform a crucial test. In these cases, the GP has taken an adequate history, performed an appropriate examination when indicated, but the penny simply has not dropped that the patient might have cancer. Based on the history and examination findings, there should have been a referral or more tests to have excluded serious pathology, as it is commonplace to have more than one working diagnosis. Once cancer was considered, referral was usually prompt. An example of failure to refer promptly when serious pathology
was a consideration involved a 65-year-old who, as a result of previous symptoms, was on a waiting list for colonoscopy and polypectomy. After six months on the waiting list, he returned to his GP with continuing intermittent bowel symptoms, but now with a recent episode of passing blood PR and a two stone weight loss. Unfortunately, he was advised to await his appointment and although the GP’s care had been exemplary until then, the resulting delay in diagnosis and consequent poor prognosis could not be defended.
RISK MANAGEMENT POINT
Be prepared to revisit the previous diagnosis. The preliminary diagnosis made here was of an intestinal polyp. With the change in symptoms, a more serious pathology was not properly considered, resulting in a delay in diagnosis.
Failure to diagnose serious illness can also occur because of systems failures. Consider the following case:
A young male patient attended
Chart 1: Top four reasons for settling GP claims
Surgical technique Failure to assess adequately Prescribing and medication errors Failure to diagnose
ARTICLE
ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011
www.medicalprotection.org
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