8 CASE 2: A common trap
Dr Hughes was doing a base session on a Saturday when Mrs Guy brought her four-year-old son Andrew to the OOH centre. Mrs Guy explained that Andrew had been unwell for three days with symptoms of lethargy, fevers, irritability, earache and loss of appetite. Dr Hughes examined
Andrew, identified that he had a red bulging left tympanic membrane, diagnosed a left otitis media and prescribed paracetamol and amoxicillin. Dr Hughes made the following entry in the records: “Off it” for 3/7: lethargic, off food, irritable, feverish and c/o otalgia. o/e temp 39.6 oC (aural), Chest – NAD, CVS – NAD, Abdo – NAD. ENT – sl red throat, bulging red left TM Diagnosis: L OM Rx Paracetamol/amoxicillin. Dr Hughes explained the
diagnosis to Mrs Guy and said that he hoped Andrew would start to improve in the next one to two days. In the early hours of Sunday morning, Andrew’s condition deteriorated and he developed a non-blanching rash. Mrs Guy was concerned about his condition and called an ambulance. At hospital a diagnosis of meningococcal septicaemia was made and the necessary treatment was instigated. Unfortunately Andrew required an amputation of several of the digits on his left foot, and developed long-term hearing loss and learning difficulties as a consequence of the disease.
Outcome Mr and Mrs Guy pursued a claim. The GP expert evidence concluded that when Dr Hughes assessed Andrew, there were several
signs and symptoms that could have been early signs of a serious underlying illness. Further to that there was no evidence that such diagnoses had been considered. Reference was made to the fact that there was no evidence of “safety-netting”. A paediatric expert concluded that an earlier admission to hospital would have led to an improved outcome. The claim was resolved by way of an early negotiated settlement.
Learning points ■■ Even if it appears that there
is an obvious diagnosis, especially in children, it is important to consider other significant diagnoses.
CASE 3: A disputed visit request
Mrs Coates rang the OOH service to discuss her 13-year-old daughter Jennifer who had woken in the night with abdominal pains and vomiting. During her call to the operator, she
asked if a doctor would come out to visit Jennifer and it was explained that the base doctor would call her back. Twenty minutes later, Dr Dunn
called Mrs Coates. She explained that Jennifer had woken at about 2am with abdominal pain, had vomited once but now appeared more settled. Dr Dunn explored other relevant aspects of the history and given that Jennifer was more settled, he suggested that she should take some paracetamol for the pain and see her own GP in the morning – with the caveat that Mrs Dunn should call again if the symptoms worsened in the interim. Despite Dr Dunn’s reassurances, Mrs
Coates remained worried and asked if a doctor would come out and see Jennifer. Dr Dunn asked Mrs Coates if she would be able to bring Jennifer to the OOH centre. Mrs Coates explained that her husband was away, her other children were asleep and it would be
inappropriate to leave them alone. Dr Dunn asked if Mrs Coates could
ask a neighbour to sit with her other children while she brought Jennifer to the centre. Mrs Coates did not feel it would be fair to wake her neighbours at this time in the morning and felt unhappy at the thought of transporting Jennifer in the car, given that she was in pain. Dr Dunn explained that the OOH
home visiting policy dictated that home visits would be reserved for terminally ill patients or those that were genuinely housebound. At this point Mrs Coates became frustrated and rang off with the parting shot: “What do I have to do to get my daughter seen by a doctor nowadays?” Over the next hour Jennifer’s symptoms worsened: Mrs Coates called an ambulance and, on admission to hospital, she was diagnosed as having appendicitis.
Outcome Mrs Coates pursued a complaint alleging that Dr Dunn declined to visit Jennifer. Mrs Coates was not happy with the response of either Dr Dunn
or the OOH provider at the conclusion of local resolution and pursued her concerns with the Parliamentary and Health Service Ombudsman (PHSO). The PHSO upheld the complaint and recommended that the OOH provider reviewed and amended their home visiting policy.
Learning points ■ ■ “Failure to visit” is a frequent cause of complaints and claims.
■■ You should put yourself in a position to justify your management plan and in the context of a patient with abdominal pain, it would be difficult to defend a claim if you have not undertaken an abdominal examination.
■■ While it is not unreasonable to explore the possibility of attending the OOH centre, there may be understandable reasons why attendance may be difficult.
■■ Avoid getting into detailed conversations about the home visiting policy.
■■ If there is any doubt, the safest option is to visit, as in the long-term this may prevent a complaint or claim.
■■ Your records should reflect that serious diagnoses have been considered and reasonably excluded.
■■ Given that a child’s condition can deteriorate quickly, you should give appropriate safety-netting advice and make reference to this in the records.
■■ Make sure that you are aware of and follow the NICE guidance, Feverish Illness in Children – www.nice.org.uk/CG47
SESSIONAL GP | VOLUME 3 | ISSUE 2 | 2011 | UNITED KINGDOM www.mps.org.uk
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