A patient attended his GP complaining of rectal bleeding, which he'd been experiencing on and off for the past year. An examination and proctoscopy didn't reveal any abnormality, and the GP asked standard questions, including whether there had been any change in bowel habit. The patient said he'd not experienced any change, but the GP didn't record this in the notes because she would generally only record positive findings.
As there was no obvious cause for the intermittent bleeding and the patient didn't meet the NICE criteria for urgent referral for an appointment within two weeks, the GP made a routine referral for surgical review and the patient was seen around five weeks later.
The patient was subsequently diagnosed with colorectal carcinoma and made a claim against the GP for failing to refer him urgently, leading to a four week delay in diagnosis. The GP contacted the MDU for advice and support.
The letter of claim alleged that if the patient had been referred under the two week rule, the tumour would have been smaller when diagnosed and the patient would have avoided four weeks of pain, suffering and anxiety.
The claim was therefore of low value, but the MDU nevertheless sought an independent GP expert's opinion, which supported the GP's management.
The records from the subsequent referral also helped, as they revealed a normal haemoglobin level and that the patient had told another clinician that his bowel habit hadn't changed, thus supporting the GP's factual account.
...recording negative findings as well as positive ones in a patient’s notes can help to provide an accurate record of events.
The MDU responded robustly to the letter of claim, denying breach of duty and emphasising that the symptoms of rectal bleeding had been going on intermittently for a year and were not associated with any altered bowel habit. Examination, including proctoscopy, had been normal, as was haemoglobin following blood tests arranged by the member, and it was also reiterated that the claimant did not meet the criteria in the NICE guidelines for a two week wait appointment.
In addition, the MDU pointed out that the case would also fail on causation given that there was no evidence in the medical records that the patient had suffered any pain or anxiety during the alleged delay.
Liability was therefore also denied, and in light of the response the patient discontinued their claim against our member.
Despite the outcome, this case shows that recording negative findings as well as positive ones in a patient's notes can help to provide an accurate record of events. Clinical records are very often a vital component in allegations of negligence, and completeness can be key.
This page was correct at publication on 14/03/2017. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.