9


and cerebral haemorrhage).4 These are shown in chart 2.


Summary From analysis of the last three years of claims, MPS has found that the four most common reasons for indefensibility of


claims in primary care are: ■■ A failure or delay in diagnosis, particularly breast, bowel and skin cancers


■■ Prescribing and medication errors


■■ Failure or inadequate assessment, particularly in the out-of-hours setting


■■ Minor surgery – cryotherapy burns and nerve damage.


Ensure your practice has a safe system for both chasing up tests you have ordered, and properly actioning them when you receive the results. We have also seen an increasing number of complaints in the out-of-hours setting, mainly due to inadequate assessment of the patient – particularly over the phone. You should be prepared to revisit both your and a colleague’s earlier diagnosis, especially when further symptoms and signs are available. Patients are also more likely to sue their doctor if they have experienced poor interpersonal communication. The communication involves not only the individual doctor but also any members of the practice team with whom they have had contact.


MPS has developed a number of focused educational and risk management programmes that could assist you in these areas – and which you can access free as a member, so do have a look at the MPS website and visit the Education section.


A successful defence Finally, I started this article by saying that almost half of all claims in primary care are discontinued or successfully defended. Whilst failure to diagnose and telephone triage remain amongst the most common pitfalls, they were also both crucial elements of a successfully defended claim in primary care. That claim involved alleged failures by a GP to diagnose premature labour, to undertake a vaginal examination


and to admit a 31-week pregnant mother to hospital immediately. The baby was born at home and was subsequently diagnosed with cerebral palsy due to a lack of appropriate resuscitation until she arrived at hospital 45 minutes after delivery, giving rise to a claim in clinical negligence for approximately £6 million. The GP was initially contacted


by a relative on behalf of the patient, the patient having experienced a short history of lower abdominal pain at 31 weeks of pregnancy. The GP asked about the nature of the pain, any vaginal discharge and whether the patient’s waters had broken. The relative was relaying the questions to the patient and the patient’s answers back to the GP, and although the GP felt reasonably confident that the answers that he had received over the telephone did not suggest labour, he nevertheless felt that this was not a satisfactory way of taking a medical history, and arranged to visit the patient after surgery, arriving just over an hour after the telephone call. After a further history and abdominal examination, which found a soft, non-tender uterus, the GP concluded that these were non-specific stretching pains rather than the onset of labour, and advised rest, paracetamol and to call again if necessary. Approximately 40 minutes later, the patient’s


500 400 300 200 100 477 0


Diagnosis 477


REFERENCES


1. Williams S, Tunnel Vision, Casebook 19(2) 2. Survey of 1,000 consecutive GP cases dealt with by MPS (2001) www.medicalprotection.org/Default.aspx?DN=32045ef8-af7a-49a7-ae4c-19a65a65649f


3. Various articles on cancer, BJGP 61 (586) (May 2011) 4. Courtesy of the Research Department, Canadian Medical Protective Association


Administration 227


Medication 167


Performance 119


Communication 81


61 Conduct 227 167 119 81 61


Note: More than one critical incident may be assigned per case; critical incidents of unknown or none are not included.


membranes ruptured and she gave birth at home. The obstetric experts agreed that this was a tragic case in which the birth did not follow the regular, frequent and painful contractions of labour normally encountered after a full term pregnancy, but instead a particular condition of pre-term birth where there is a slow and insidious labour followed by a precipitate delivery. The GP experts agreed that a reasonably competent GP could neither be expected to


Ensure your practice has a safe system for both chasing up tests you have ordered, and properly actioning them when you receive the results


have encountered, nor to be aware of, this extremely unusual presentation of pre-term labour. The court accepted the GP’s clear and consistent evidence that there were no signs of labour at the time of the visit, and that neither vaginal examination nor emergency admission to hospital were indicated. The judge therefore found in the favour of the GP, who had undertaken an adequate assessment in the circumstances, and the claim against him was dismissed.


Thanks to Dr Mark Dinwoodie, MPS Education and Risk Management and Elise Amyot, and the Research Department, Canadian Medical Protective Association, for their contributions.


Chart 2: Critical incident groupings, family, practitioner settlement cases, CMPA 2006 – 2010


ARTICLE


ASIA CASEBOOK | VOLUME 19 | ISSUE 3 | SEPTEMBER 2011 www.medicalprotection.org


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