A woman in her late forties with Crohn's disease and hypertension called her surgery one evening complaining of the sudden onset of numbness in her left leg. She was visited by a locum, who found no abnormality apart from numbness. He diagnosed sciatic nerve root irritation, and recommended bed rest with painkillers.
Three days later, the patient, now in some pain, was seen as an emergency at the surgery. One of the partners noted a slight reduction in the left ankle sensation. He made a preliminary diagnosis of a trapped nerve, and prescribed bed rest and stronger painkillers.
Three days later, she was seen again by the same doctor, complaining of more severe pain, and a cold sensation down her left leg. She was unable to dorsiflex her ankle and plantar flexion was very weak. He discussed his initial diagnosis with an orthopaedic registrar who advised strict bed rest with painkillers and muscle relaxants.
The patient's own GP visited her after she complained she had not slept for two days because of severe pain. He noted her left foot was colder than her right, but noticed no colour change. He discussed the case with an orthopaedic registrar who advised an urgent out-patient appointment. Another partner in the practice visited her the next day after she complained of vomiting, and gave her an anti-emetic injection.
Three days later, the patient's GP admitted her to hospital as an emergency. The numbness had extended to the whole of her left leg and she was unable to stand. A surgical registrar noted she had suffered severe arterial occlusion for one week. Despite anticoagulation treatment and an embolectomy, the condition of her leg continued to deteriorate. An above knee amputation was performed.
The patient alleged all four doctors had failed to recognised that she was suffering from ischaemia, and refer her immediately to hospital. She said the three GPs from her local surgery had persisted with a diagnosis of lower back pain, despite evidence to the contrary. Because of the amputation, the patient had been unable to return to her full-time job, and was forced to take part-time work. Her house had to be adapted because of her disability.
The MDU obtained a number of expert opinions. One consultant surgeon said that an acute thrombosis of the aorto-iliac artery was extremely unusual in a woman of her age, but added that the "sudden onset of symptoms... on the evening the locum visited should certainly have suggested the possibility of arterial occlusion."
A GP expert said that on the day the woman's own GP visited, her femoral pulse would have been absent "...which is a very gross physical sign and impossible to miss..." The GP had examined the pulses in the foot, which were difficult to find, and not very strong. The expert said: "I feel this was a missed opportunity to get the patient seen or admitted in view of his concern."
It was acknowledged that the leg would probably have been saved if the patient's own GP had admitted her to hospital on that day.
No contribution was sought from the health authority because although it was felt that admission should have been advised by the registrars who were consulted, it was recognised that the GP missed a later opportunity to admit at a time when the leg could have been saved.
The MDU decided in the face of the expert opinion there was a substantial risk that the patient would be successful in at least some of her allegations. A settlement was agreed at £200,000 (90% MDU, 10% another medical defence organisation), to reflect the loss of earnings and the cost of adapting the house, in addition to pain and suffering.
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