The patient, a woman in her twenties, had suffered from asthma since childhood. She had experienced several acute attacks which had led her to refer herself to hospital on a number of occasions. She regularly attended her practice asthma clinic where she was monitored and her peak flow rate (PFR) recorded.
She was also issued with a PF meter and nebuliser for home use. She had been intermittently treated with both inhaled and oral steroids. For the past year her asthma had been well-controlled with steroid inhalers.
The patient visited her GP to confirm a pregnancy and indicated that she intended to discontinue using her steroid inhaler because of possible risk to the baby. The GP reassured her that the risk was minimal but that 100% safety could not be guaranteed with any drug.
She advised the patient that the risk of suffering an acute attack posed a far greater threat to the foetus. The patient, who had remained well throughout a previous pregnancy without steroids, chose not to follow this advice.
Two weeks later the patient visited her GP's partner complaining of tightness and wheeziness and asked for a prescription for nebules. Her PFR was 150, 40% of her average best. Her overall clinical condition was inconsistent with such a low reading: she was able to walk and talk easily, she was not distressed and she was not coughing or wheezing.
The GP restated the benefits of steroid inhalers in the management of asthma and explained that the low PFR placed her at risk of a severe attack which would mean hospital admission and intravenous steroids. The patient again refused steroid inhalers. She was issued with a prescription for nebules and the GP checked that she was familiar with the surgery's open access policy for known asthmatics.
A few days later the patient asked for a non-urgent home visit. The patient's GP was on call and she spoke to the patient who reported feeling wheezy and thought she might need antibiotics. She was able to speak without difficulty. The GP attended and found the patient tired but comfortable in bed.
She discussed her general condition and, on examination, found that her PFR had dropped to below 100, which gave cause for concern. She arranged admission with the hospital, telephoned the ambulance service requesting an immediate ambulance, and then administered nebulised bronchodilator. By this stage the patient's PFR had fallen to 60 and she was becoming increasingly breathless and distressed.
Two further calls were made to the ambulance service: the first by the patient's husband and the second by the GP. On both occasions they were told that the ambulance was on its way. The ambulance finally arrived 40 minutes later.
The GP accompanied the patient to hospital in the ambulance. The patient was given oxygen on the journey. On arrival at the hospital the patient suffered a respiratory arrest and cerebral hypoxia resulting in miscarriage and brain damage.
Proceedings were brought against both GPs and the ambulance service. It was alleged that both GPs had failed to impress upon the patient the importance of prophylactic therapy appropriate to her asthmatic condition and had allowed her to stop taking inhaled steroids. In the light of this knowledge, they had also failed to monitor her condition adequately, or to advise her to monitor her own condition adequately.
Further allegations were made against the attending GP. It was claimed that she had failed to ensure immediate admission of the patient to hospital and that her treatment of her while awaiting the ambulance was below that which could reasonably have been expected.
It was alleged that the ambulance service failed to respond adequately to the doctor's call and delayed in providing an ambulance to transfer the patient from her home to hospital.
All three parties contested the allegations.
The MDU consulted two experts on behalf of the GPs. Both were in agreement that: '...the defendants' practice was at the cutting edge of good clinical practice insofar as its treatment of asthmatics was concerned '. Because of this the patient was well-educated about her condition and competent in monitoring it herself.
In the experts' opinion the crucial issue in the outcome of this case was the patient's unwillingness to accept steroid therapy, either prophylactically or at the onset of the attack.
They also felt that the attending GP's decision not to give aminophylline by slow intravenous injection, (a 30-minute procedure), while awaiting the ambulance was defensible, given that the ambulance was expected within minutes.
The experts' conclusion was that ultimately patients are in charge of their own destiny and a doctor can only give appropriate warning of the consequences of acting against medical advice.
The case went to trial where the judge dismissed the case against both GPs. In a landmark ruling he found against the ambulance service, saying that they had failed in their duty of care because there was an unacceptable delay in arriving at the patient's home. They were ordered to pay in excess of £350,000 damages.
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