CASE studies


BACKGROUND: A 48-year-old patient – Mr p – attends his local surgery with a two-day history of urinary tract symptoms: frequency and urgency. His Gp – Dr K – examines the patient and fi nds: “No palpable bladder, apyrexial, urine cloudy with mucous. Test positive for blood, protein, leucocytes.” The GP also notes that Mr P has had a history of bladder outfl ow problems in childhood for which he had surgery. Dr K diagnoses urinary tract


infection (UTI) and prescribes the antibiotic trimethoprim. Urine culture later confi rms the infection. Two days later Mr P phones the surgery and speaks to Dr K reporting an improvement in symptoms but that he feels intermittent blockage and that his urine is still cloudy. Dr K makes a routine non-urgent referral for Mr P to a urology outpatient clinic. Two months later Mr P is


seen at the outpatient clinic. He again complains of persistent frequency and urgency. A staff grade physician measures fl ow rate and performs an ultrasound scan to assess bladder emptying. This reveals no abnormality and no further investigations are undertaken. A week later the patient


requests an emergency appointment at the surgery and sees a diff erent GP. He has blood in his urine but the GP notes that the patient was only just recently assessed and


20


These studies are based on actual cases from MDDUS fi les and are published in Summons to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confi dentiality


DIAGNOSIS: HAEMATURIA NOTED


given an all-clear. Mr P is prescribed more antibiotics and told to present a urine sample in 10 days. Later that week Mr P makes


another appointment at the surgery and sees Dr K. The GP notes that the patient is passing urine 20-30 times per day and with signifi cant diffi culty. He is also passing blood. Dr K makes an urgent referral under the two-week cancer rule and records in the referral letter that the patient has both white and red blood cells present in his urine. Four days later Mr P is seen


at the urology clinic. An SpR arranges for an ultrasound and cystoscopy to investigate the cause of the patient’s recurrent UTI. The tests reveal a bladder cancer invading muscle. A CT scan shows that Mr P already has metastatic disease. A transurethral resection is carried out and chemotherapy organised with an oncologist. The patient fails to respond to treatment and dies three months later. Six months later a letter


arrives from solicitors acting on behalf of Mr P’s family alleging clinical negligence against Dr K for not referring the patient for urgent investigation after the initial consultation. This would have allowed diagnosis and treatment of the carcinoma before it metastasised.


ANALYSIS/OUTCOME: Dr K contacts MDDUS and expert opinions are commissioned


from both a primary care physician and a consultant urologist. In the letter of claim it’s alleged that Mr P had complained of frank haematuria with clotting but this is not refl ected in Dr K’s notes – and it is on the basis of the recorded observations that the GP made a non-urgent referral in the initial consultation. The diagnosis of UTI was confi rmed by culture and the GP’s judgment was further supported by the fact no abnormality was noted when Mr P was eventually seen in the outpatient clinic. The primary care expert off ers the opinion that a competent GP acting with reasonable care would have managed the patient in a similar way to Dr K. The urologist is of the same opinion that Mr P’s symptoms at the initial consultation with Dr K were consistent with UTI. However, he is critical of the


attending physician at the fi rst outpatient consultation. In his opinion standard practice with symptoms of urgency would have warranted a cystoscopy to rule out bladder pathology. In the question of possible


causation the urologist states that even had the tumour being diagnosed in an urgent referral after the fi rst consultation it is likely there was already metastatic disease present. MDDUS solicitors off er a denial of liability and rebuttal of causation. No further action is pursued by the family.


KEY POINTS •


•


Clear and comprehensive records are key in defending negligence claims.


More than one positive test result for haematuria merits further investigation.


• Recurrent urinary tract infection is a red fl ag, especially in men.


SUMMONS


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24